additional information specification 0003: rehabilitation … · 2018-10-24 · additional...

Copyright © 1998-2004 Health Level Seven. All Rights Reserved.

CDAR1AIS0003R021

Additional Information Specification 0003: Rehabilitation Services Attachment

(This specification replaces Additional Information Message 0003: Rehabilitation Services Attachment

September 1, 2002)

Release 2.1 Based on HL7 CDA Standard Release 1.0,

with supporting LOINC® Tables

May 2004

Additional Information Specification 0003: Rehabilitation Services Attachment CDAR1AIS0003R021

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Copyright © 1998-2004 Health Level Seven, Inc. All rights reserved. Release 2.1 Final Standard

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Table of Contents

1 INTRODUCTION................................................................................................................................................................1 1.1 LOINC CODES AND STRUCTURE ................................................................................................................................... 1 1.2 REVISION HISTORY........................................................................................................................................................... 3 1.3 PRIVACY CONCERNS IN EXAMPLES............................................................................................................................... 3 1.4 HL7 ATTACHMENT -CDA DOCUMENT VARIANTS...................................................................................................... 3 1.5 REQUEST FOR INFORMATION VERSUS REQUEST FOR SERVICE.................................................................................. 3

2 LOINC CODES .....................................................................................................................................................................4 2.1 REHABILITATION SERVICES SUPPORTING DOCUMENTATION.................................................................................... 4 2.2 SCOPE MODIFICATION CODES........................................................................................................................................ 4 2.3 SPECIAL CONSIDERATIONS FOR SENDING MEDICATIONS.......................................................................................... 4 2.4 ATTACHMENT DATA COMPONENTS............................................................................................................................... 4

2.4.1 Alcohol-Substance Abuse Rehabilitation Attachment.................................................................................... 5 2.4.2 Cardiac Rehabilitation Attachment.................................................................................................................... 7 2.4.3 Medical Social Services Rehabilitation Attachment....................................................................................... 7 2.4.4 Occupational Therapy Rehabilitation Attachment .......................................................................................... 8 2.4.5 Physical Therapy Rehabilitation Attachment................................................................................................... 9 2.4.6 Psychiatric Rehabilitation Attachment............................................................................................................ 10 2.4.7 Respiratory Therapy Rehabilitation Attachment........................................................................................... 10 2.4.8 Skilled Nursing Rehabilitation Attachment.................................................................................................... 11 2.4.9 Speech Therapy Rehabilitation Attachment................................................................................................... 12

3 REHABILITATION SERVICES ATTACHMENT VALUE TABLES ..............................................................13 3.1 ALCOHOL-SUBSTANCE ABUSE REHABILITATION SERVICE VALUE TABLE........................................................... 13 3.2 CARDIAC REHABILITATION SERVICE VALUE TABLE................................................................................................ 19 3.3 MEDICAL SOCIAL SERVICES REHABILITATION VALUE TABLE ............................................................................... 22 3.4 OCCUPATIONAL THERAPY REHABILITATION SERVICE VALUE TABLE................................................................... 25 3.5 PHYSICAL THERAPY REHABILITATION VALUE TABLE............................................................................................. 28 3.6 PSYCHIATRIC REHABILITATION SERVICE VALUE TABLE......................................................................................... 31 3.7 RESPIRATORY THERAPY REHABILITATION SERVICE VALUE TABLE...................................................................... 34 3.8 SKILLED NURSING REHABILITATION SERVICE VALUE TABLE................................................................................ 37 3.9 SPEECH THERAPY REHABILITATION SERVICE VALUE TABLE................................................................................. 40

4 CODING EXAMPLES ......................................................................................................................................................43 4.1 SCENARIO ........................................................................................................................................................................ 43

4.1.1 Coded Rehabilitation Plan, Human-Decision Variant.................................................................................. 44 4.1.2 Coded Rehabilitation Plan, Computer-Decision Variant ............................................................................. 50

5 RESPONSE CODE SETS ................................................................................................................................................59 5.1 HL70136: HL7 YES-NO INDICATOR........................................................................................................................... 59 5.2 HL70162: HL7 ROUTE OF MEDICINE ADMINISTRATION......................................................................................... 59 5.3 HL79002: HL7 REHABILITATION PLAN STATUS....................................................................................................... 60 5.4 HL79003: HL7 REHABILITATION PLAN CONTINUE/DISCONTINUE INDICATOR................................................... 60 5.5 HL79005: HL7 REHABILITATION PLAN PROGNOSIS................................................................................................ 60 5.6 HL79006: HL7 REHABILITATION SERVICE REMISSION STATUS ............................................................................ 60 5.7 HL79015: HL7 FREQUENCY BASE PERIOD................................................................................................................ 61 5.8 I9C : ICD-9-CM ............................................................................................................................................................. 61 5.9 ISO+: EXTENDED ISO UNITS CODES............................................................................................................................ 61 5.10 NDC: NATIONAL DRUG CODE ................................................................................................................................ 61 5.11 NPI: NATIONAL PROVIDER IDENTIFIER................................................................................................................. 61 5.12 PTX: HEALTH CARE PROVIDER TAXONOMY........................................................................................................ 62


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Index of Tables and Figures Table 1.1 Relationship of LOINC Codes, X12N Transactions, and HL7 CDA Documents.............................................. 2 Table 2.1 LOINC codes for a complete rehabilitation attachment data set........................................................................... 4 Table 2.4.1 Data Components for Alcohol-Substance Abuse Rehabilitation Attachment.................................................. 5 Table 2.4.2 Data Components for Cardiac Rehabilitation Attachment.................................................................................. 7 Table 2.4.3 Data Components for Medical Social Services Rehabilitation Attachment..................................................... 7 Table 2.4.4 Data Components for Occupational Therapy Rehabilitation Attachment ........................................................ 8 Table 2.4.5 Data Components for Physical Therapy Rehabilitation Attachment................................................................. 9 Table 2.4.6 Data Components for Psychiatric Rehabilitation Attachment.......................................................................... 10 Table 2.4.7 Data Components for Respiratory Therapy Rehabilitation Attachment ......................................................... 10 Table 2.4.8 Data Components for Skilled Nursing Rehabilitation Attachment.................................................................. 11 Table 2.4.9 Data Components for Speech Therapy Rehabilitation Attachment................................................................. 12 Table 3.1 Alcohol-Substance Abuse Rehabilitation Service Value Table ........................................................................... 13 Table 3.2 Cardiac Rehabilitation Service Value Table ........................................................................................................... 19 Table 3.3 Medical Social Services Rehabilitation Value Table............................................................................................. 22 Table 3.4 Occupational Therapy Rehabilitation Service Value Table ................................................................................. 25 Table 3.5 Physical Therapy Rehabilitation Service Va lue Table .......................................................................................... 28 Table 3.6 Psychiatric Rehabilitation Service Value Table ..................................................................................................... 31 Table 3.7 Respiratory Therapy Rehabilitation Service Value Table .................................................................................... 34 Table 3.8 Skilled Nursing Rehabilitation Service Value Table ............................................................................................. 37 Table 3.9 Speech Therapy Rehabilitation Service Value Table ............................................................................................ 40 Figure 4.1 Psychiatric Rehabilitation Plan Data....................................................................................................................... 43 Example 4.1.1 Psychiatric Rehabilitation Plan, Human-Decision Variant.......................................................................... 44 Figure 1. Portion of Rendered Human-Decision Variant........................................................................................................ 49 Example 4.1.2 Psychiatric Rehabilitation Plan, Computer-Decision Variant..................................................................... 50 Table 5.1 HL7 Yes-No Indicator................................................................................................................................................. 59 Table 5.2 - Route of administration............................................................................................................................................ 59 Table 5.3 HL7 Rehabilitation Plan Status................................................................................................................................. 60 Table 5.4 HL7 Rehabilitation Plan Continue/Discontinue Indicator................................................................................... 60 Table 5.5 HL7 Rehabilitation Plan Prognosis........................................................................................................................... 60 Table 5.6 HL7 Rehabilitation Service Remission Status........................................................................................................ 60 Table 5.7 HL7 Frequency Base Period ...................................................................................................................................... 61



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1 Introduction This publication provides the LOINC®1 code values specific to a rehabilitation services attachment for the following applications.

• Those codes that define the attachment or attachment components used in transactions such as those defined by the ASC X12N 277 (004050X150) Health Care Claim Request for Additional Information and the ASC X12N 275 (004050X151) Additional Information to Support a Health Care Claim or Encounter Implementation Guides which are products of the insurance subcommittee, X12N, of Accredited Standards Committee X12. 2,3

• All of the codes may be used in HL7 Clinical Document Architecture (CDA) documents designed for inclusion in the BIN segment of the 275 transaction as described in the HL7 Additional Information Specification Implementation Guide4

The format of this document and the methods used to arrive at its contents are prescribed in the HL7 Additional Information Specification Implementation Guide.

Section 2 of this document defines the LOINC codes used to request rehabilitation services attachments, and the LOINC codes of each component in an attachment. Section 3 further describes each component of a specific rehabilitation services attachment, the cardinality of the components and their answer parts, and the description, data types, codes, and units of each answer part.

Section 4 presents coding examples, with a narrative scenario, an XML example, and a display image of each example attachment using a popular browser. Section 5 further describes the code sets used in the response to each answer part of the attachment.

Note: All LOINC codes and descriptions are copyrighted by the Regenstrief Institute, with all rights reserved. See http://www.LOINC.org.

1.1 LOINC Codes and Structure

LOINC codes are used for several purposes:

• In the X12N 277 transaction set, LOINC codes identify the attachment or attachment components being requested to support a claim or encounter.

• In the HL7 CDA document, LOINC codes are used to identify the attachment, the attachment components, and their answer parts. This is returned in the X12N 275 transaction set.

• LOINC modifier codes may be used in the 277 transaction to further define the specificity of a request.

1 LOINC® is a registered trademark of Regenstrief Institute and the LOINC Committee. The LOINC database and LOINC Users’ Guide are copyright 1998-2004 Regenstrief Institute and the LOINC Committee and the LOINC database codes and names are available at no cost from http://www.LOINC.org. Regenstrief Institute, 1050 Wishard Blvd., Indianapolis, IN 46202 Email: [email protected] 2Information on this and other X12N/HIPAA-related implementation guides is available from the Washington Publishing Company, PMB 161, 5284 Randolph Rd., Rockville, MD 20852-2116. Phone: 800-972-4334. or http://www.wpc-edi.com/ 3 Within this Health Level Seven document, references to the transaction defined by these X12N implementation guides will be abbreviated by calling them 275 and 277. 4 Health Level Seven, Inc. 3300 Washtenaw Ave., Suite 227, Ann Arbor, MI 48104-4250. (http://www.hl7.org)


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Table 1.1 Relationship of LOINC Codes, X12N Transactions, and HL7 CDA Documents.

X12N 277 X12N 275 HL7 CDA

Purpose of Attachment

Request for additional information to support a health care claim

Additional information to support a health care claim or encounter

Provide controlled content for X12N 275 BIN segment

LOINC Modifier

Codes

Used in the STC segment to limit the scope or time frame of a request for information. e.g., § Send information for up to 90 days before the related encounter

Reiterated in the STC segment

Not used in the CDA document

LOINC Attachment Identifier

Used in the STC segment to request an attachment in its entirety, e.g., § Send the rehab treatment plan


Used in the <document_type_cd> element of the header

LOINC Attachment Component

Used in the STC segment to request a specific attachment component or part of a clinical report, .e.g., § Send the rehab treatment plan author


Used in the computer-decision CDA variant in the <caption_cd> element of a <section> to identify the attachment component being provided, e.g., This is the author information

LOINC Attachment Component Answer Part

Not used in the 277

Not used in the 275 except within the

CDA instance document in the BIN segment.

Used in the computer-decision CDA variant in the <caption_cd> element of a <paragraph>, an <item> element within a <list> or a <td> element within a <table> to identify the answer part of an attachment component being provided, e.g., This is the name, identifier and taxonomy



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1.2 Revision History

Date Purpose Sep 30, 1998 Initial release as separate document.

Dec 2001 Revised title and date; reconciled HL7 ballot responses August 2003 CDA Ballot

December 2003 Version 2.0 Publication December 2003 Release 2.1 Ballot

May 2004 Release 2.1 Publication

1.3 Privacy Concerns in Examples The names of natural persons that appear in the examples of this book are intentionally fictional. Any resemblance to actual natural persons, living or deceased is purely coincidental.

1.4 HL7 Attachment-CDA Document Variants As described in the HL7 Additional Information Specification Implementation Guide, there are two variants of a CDA document when used as an attachment.

The human-decision variant is used solely for information that will be rendered for a person to look at, in order to make a decision. HL7 provides a non-normative style sheet for this purpose. There are two further alternatives within the human-decision variant.

• non_xml body: The information can be sent with a CDA header structured in XML, along with a "non_xml body" that references scanned images of documents that contain the submitted information

• xml body: the information can be sent as free text in XML elements that organize the material into sections, paragraphs, tables and lists as described in the HL7 Additional Information Specification Implementation Guide.

The computer-decision variant has the same content as the human-decision variant, but additional coded and structured information is included so that a computer could provide decision support based on the document. Attachments in the computer-decision variant can be rendered for human decisions using the same style sheet that HL7 provides for rendering documents formatted according to the human-decision variant.

1.5 Request for Information versus Request for Service

This attachment specification for rehabilitation services defines a “send-me-what-you-have” attachment. It asks for a set of rehabilitation services attachment components gathered during the rehabilitation services care process. It is not asking for any additional data capture efforts. For example, if the request for data is to send the longest term of sobriety and this information was not captures at the time of care, it is not asking the provider to obtain additional information if they don’t already have this information.

In any attachment component answer part it may sometimes be impossible to send a required answer and necessary to send, instead, a reason why the information is not available. In the human decision variant the sender shall supplement the natural language explanation of why the information is not available with local markup. In the computer-decision variant the sender shall include local markup to describe the reason that the information is not available as described in the Data Types section of the HL7 Additional Information Specification Implementation


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2 LOINC Codes

2.1 Rehabilitation Services Supporting Documentation

Table 2.1 defines the LOINC codes used to request a complete attachment data set specific to a given rehabilitation treatment plan. The use of any of these codes in the 277 STC segment represents an explicit request for the complete set of data components relevant to the requested rehabilitation treatment plan.

The provider shall return all data components for which data is available.

The provider may choose to return images of pages that constitute the requested information by using the <non_xml> element of the CDA as described in the HL7 Additional Information Specification Implementation Guide.

The set of data components for each rehabilitation service attachment, identified by individual LOINC codes, is defined in Section 2.4.

Table 2.1 LOINC codes for a complete rehabilitation attachment data set

2.2 Scope Modification Codes The HL7 publication LOINC Modifier Codes (for use with ASC X12N Implementation Guides when Requesting Additional Information) provides code values for further defining the specificity of a request for additional information. Both time window and item selection modifier codes are defined. This publication is available from HL7, and is in the download package with the AIS documents.

2.3 Special Considerations for Sending Medications The LOINC codes for rehabilitation plans include some that can be used to request or send medications used as part of a plan. The considerations for sending medications are described in Section 2 of Additional Information Specification 0006: Medications Attachment. The sender shall use the instructions in that document for sending medications in rehabilitation plans.

2.4 Attachment Data Components

Individual LOINC codes are defined for each data component of the attachment specific to the disciplines listed in Table 2.1. These LOINC codes are listed in sections 2.4.1 to 2.4.9 respectively. For example, the data components comprising the cardiac rehabilitation attachment (LOINC

LOINC code Attachment Name 18823-5 Alcohol-substance abuse rehabilitation attachment 18824-3 Cardiac rehabilitation attachment 18825-0 Medical social services rehabilitation attachment 18826-8 Occupational therapy rehabilitation attachment 19002-5 Physical therapy rehabilitation attachment 18594-2 Psychiatric rehabilitation attachment 19003-3 Respiratory therapy rehabilitation attachment 19004-1 Skilled nursing rehabilitation attachment 29206-0 Speech therapy rehabilitation attachment



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18824-3) appear in Table 2.4.2. Each table is headed by the LOINC code defining the complete attachment.

The LOINC codes in Table 2.1 represent requests for complete rehabilitation services attachments. However, the requester also has the option of focusing on a specific component of the attachment through the use of the LOINC codes defined in the following tables. In this case the provider will respond with information, where available, specific to the requested data components.

The attachment content of seven of the disciplines (cardiac rehabilitation, medical social services, occupational therapy, physical therapy, respiratory therapy, skilled nursing and speech therapy) is virtually identical. The data components differ only by the name of the discipline. Psychiatric and alcohol-substance abuse attachments include the same general content with the addition of several data components unique to those disciplines.

The following tables show the specific data components and their LOINC codes for each of the nine rehabilitation disciplines. These LOINC codes may be used in ASC X12N 277 as defined in the associated Implementation Guide and will be mirrored in the corresponding ASC X12N 275 response. In addition, these LOINC codes are used in the <caption_cd> element of the computer-decision variant of HL7 Additional Information Specification Implementation Guide. The questions that these LOINC codes represent are the result of a significant industry outreach project and represent the complete set of rehabilitation services attachment components.

2.4.1 Alcohol-Substance Abuse Rehabilitation Attachment

Table 2.4.1 Data Components for Alcohol-Substance Abuse Rehabilitation Attachment

LOINC Code Description 18823-5 ALCOHOL-SUBSTANCE ABUSE REHABILITATION ATTACHMENT 27474-6 ALCOHOL-SUBSTANCE ABUSE REHABILITATION TREATMENT PLAN, NEW/REVISED 27801-0 ALCOHOL-SUBSTANCE ABUSE REHABILITATION TREATMENT PLAN, DATE ONSET

OR EXACERBATION OF PRIMARY DIAGNOSIS 27475-3 ALCOHOL-SUBSTANCE ABUSE REHABILITATION TREATMENT PLAN, START DATE 27515-6 ALCOHOL-SUBSTANCE ABUSE REHABILITATION TREATMENT PLAN, PRIMARY

DIAGNOSIS 27477-9 ALCOHOL-SUBSTANCE ABUSE REHABILITATION TREATMENT PLAN, DIAGNOSIS

ADDRESSED BY PLAN 27478-7 ALCOHOL-SUBSTANCE ABUSE REHABILITATION TREATMENT PLAN, AUTHOR OF

TREATMENT PLAN 27482-9 ALCOHOL-SUBSTANCE ABUSE REHABILITATION TREATMENT PLAN, VISIT

FREQUENCY 27487-8 ALCOHOL-SUBSTANCE ABUSE REHABILITATION TREATMENT PLAN, DATE RANGE

(FROM/THROUGH) DESCRIBED BY PLAN 27490-2 ALCOHOL-SUBSTANCE ABUSE REHABILITATION TREATMENT PLAN, DATE RANGE

(FROM/THROUGH) OF HOSPITALIZATION LEADING TO TREATMENT 27491-0 ALCOHOL-SUBSTANCE ABUSE REHABILITATION TREATMENT PLAN,

CONTINUATION STATUS 27492-8 ALCOHOL-SUBSTANCE ABUSE REHABILITATION TREATMENT PLAN, DATE

ATTENDING MD REFERRED PATIENT FOR TREATMENT 27493-6 ALCOHOL-SUBSTANCE ABUSE REHABILITATION TREATMENT PLAN, DATE

ATTENDING MD SIGNED 27494-4 ALCOHOL-SUBSTANCE ABUSE REHABILITATION TREATMENT PLAN, DATE REHAB

PROFESSIONAL SIGNED 27495-1 ALCOHOL-SUBSTANCE ABUSE REHABILITATION TREATMENT PLAN, SIGNATURE

OF RESPONSIBLE ATTENDING MD ON FILE 27496-9 ALCOHOL-SUBSTANCE ABUSE REHABILITATION TREATMENT PLAN, SIGNATURE

OF RESPONSIBLE REHAB PROFESSIONAL ON FILE 27498-5 ALCOHOL-SUBSTANCE ABUSE REHABILITATION TREATMENT PLAN, MEDICATION

ADMINISTERED


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LOINC Code Description 27499-3 ALCOHOL-SUBSTANCE ABUSE REHABILITATION TREATMENT PLAN, PROGNOSIS

FOR REHABILITATION 27500-8 ALCOHOL-SUBSTANCE ABUSE REHABILITATION TREATMENT PLAN, ESTIMATED

DATE OF COMPLETION 27501-6 ALCOHOL-SUBSTANCE ABUSE REHABILITATION TREATMENT PLAN, DATE OF LAST

PLAN OF TREATMENT CERTIFICATION 27502-4 ALCOHOL-SUBSTANCE ABUSE REHABILITATION TREATMENT PLAN, PAST

MEDICAL HISTORY + LEVEL OF FUNCTION 27503-2 ALCOHOL-SUBSTANCE ABUSE REHABILITATION TREATMENT PLAN, INITIAL

ASSESSMENT 27504-0 ALCOHOL-SUBSTANCE ABUSE REHABILITATION TREATMENT PLAN, PLAN OF

TREATMENT 27505-7 ALCOHOL-SUBSTANCE ABUSE REHABILITATION TREATMENT PLAN, PROGRESS

NOTE + ATTAINMENT OF GOALS 27506-5 ALCOHOL-SUBSTANCE ABUSE REHABILITATION TREATMENT PLAN, REASON TO

CONTINUE 27507-3 ALCOHOL-SUBSTANCE ABUSE REHABILITATION TREATMENT PLAN,

JUSTIFICATION 18662-7 ALCOHOL-SUBSTANCE ABUSE REHABILITATION TREATMENT PLAN, CHIEF

COMPLAINT + REASON FOR REFERRAL + REASON FOR RELAPSE IF KNOWN 18663-5 ALCOHOL-SUBSTANCE ABUSE REHABILITATION TREATMENT PLAN, HISTORY OF

PRESENT ALCOHOL/SUBSTANCE ABUSE 18664-3 ALCOHOL-SUBSTANCE ABUSE REHABILITATION TREATMENT PLAN, FOLLOWUP

APPROACH 18669-2 ALCOHOL-SUBSTANCE ABUSE REHABILITATION TREATMENT PLAN, LEVEL OF

PATIENT PARTICIPATION 27513-1 ALCOHOL-SUBSTANCE ABUSE REHABILITATION TREATMENT PLAN, DATE RANGE

(FROM/THROUGH) OF NEXT PLANNED REHABILITATION TREATMENT 18671-8 ALCOHOL-SUBSTANCE ABUSE REHABILITATION TREATMENT PLAN, NEXT PLAN

OF TREATMENT TEXT 18672-6 ALCOHOL-SUBSTANCE ABUSE REHABILITATION TREATMENT PLAN,

ALCOHOL/SUBSTANCE ABUSE SYMPTOMS WITH PHYSIOLOGICAL DEPENDENCE INDICATOR

18673-4 ALCOHOL-SUBSTANCE ABUSE REHABILITATION TREATMENT PLAN, REHABILITATION PROBLEM REMISSION STATUS

18674-2 ALCOHOL-SUBSTANCE ABUSE REHABILITATION TREATMENT PLAN, LONGEST PERIOD OF SOBRIETY FOR ABUSED SUBSTANCE



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2.4.2 Cardiac Rehabilitation Attachment

Table 2.4.2 Data Components for Cardiac Rehabilitation Attachment

2.4.3 Medical Social Services Rehabilitation Attachment

Table 2.4.3 Data Components for Medical Social Services Rehabilitation Attachment

LOINC Code Description 18825-0 MEDICAL SOCIAL SERVICES REHABILITATION ATTACHMENT

27750-9 MEDICAL SOCIAL SERVICES TREATMENT PLAN, NEW/REVISED 27751-7 MEDICAL SOCIAL SERVICES TREATMENT PLAN, DATE ONSET OR EXACERBATION

OF PRIMARY DIAGNOSIS 27752-5 MEDICAL SOCIAL SERVICES TREATMENT PLAN, START DATE 27791-3 MEDICAL SOCIAL SERVICES TREATMENT PLAN, PRIMARY DIAGNOSIS 27754-1 MEDICAL SOCIAL SERVICES TREATMENT PLAN, DIAGNOSIS ADDRESSED BY PLAN 27755-8 MEDICAL SOCIAL SERVICES TREATMENT PLAN, AUTHOR OF TREATMENT PLAN 27759-0 MEDICAL SOCIAL SERVICES TREATMENT PLAN, VISIT FREQUENCY 27761-6 MEDICAL SOCIAL SERVICES TREATMENT PLAN, DATE RANGE (FROM/THROUGH)

DESCRIBED BY PLAN

LOINC Code Description 18824-3 CARDIAC REHABILITATION ATTACHMENT

27483-7 CARDIAC REHABILITATION TREATMENT PLAN, NEW/REVISED 27484-5 CARDIAC REHABILITATION TREATMENT PLAN, DATE ONSET OR EXACERBATION

OF PRIMARY DIAGNOSIS 27485-2 CARDIAC REHABILITATION TREATMENT PLAN, START DATE 27457-1 CARDIAC REHABILITATION TREATMENT PLAN, PRIMARY DIAGNOSIS 27518-0 CARDIAC REHABILITATION TREATMENT PLAN, DIAGNOSIS ADDRESSED BY PLAN 27519-8 CARDIAC REHABILITATION TREATMENT PLAN, AUTHOR OF TREATMENT PLAN 27531-3 CARDIAC REHABILITATION TREATMENT PLAN, VISIT FREQUENCY 27533-9 CARDIAC REHABILITATION TREATMENT PLAN, DATE RANGE (FROM/THROUGH)

DESCRIBED BY PLAN 27536-2 CARDIAC REHABILITATION TREATMENT PLAN, DATE RANGE (FROM/THROUGH) OF

HOSPITALIZATION LEADING TO TREATMENT 27539-6 CARDIAC REHABILITATION TREATMENT PLAN, CONTINUATION STATUS 27540-4 CARDIAC REHABILITATION TREATMENT PLAN, DATE ATTENDING MD REFERRED

PATIENT FOR TREATMENT 27541-2 CARDIAC REHABILITATION TREATMENT PLAN, DATE ATTENDING MD SIGNED 27542-0 CARDIAC REHABILITATION TREATMENT PLAN, DATE CARDIAC REHABILITATION

PROFESSIONAL SIGNED 27543-8 CARDIAC REHABILITATION TREATMENT PLAN, SIGNATURE OF RESPONSIBLE

ATTENDING MD ON FILE 27544-6 CARDIAC REHABILITATION TREATM ENT PLAN, SIGNATURE OF RESPONSIBLE

CARDIAC REHABILITATION PROFESSIONAL ON FILE 27545-3 CARDIAC REHABILITATION TREATMENT PLAN, MEDICATION ADMINISTERED 27546-1 CARDIAC REHABILITATION TREATMENT PLAN, PROGNOSIS FOR CARDIAC

REHABILITATION 27547-9 CARDIAC REHABILITATION TREATMENT PLAN, ESTIMATED DATE OF COMPLETION 27548-7 CARDIAC REHABILITATION TREATMENT PLAN, DATE OF LAST PLAN OF

TREATMENT CERTIFICATION 27549-5 CARDIAC REHABILITATION TREATMENT PLAN, PAST MEDICAL HISTORY + LEVEL

OF FUNCTION 27445-6 CARDIAC REHABILITATION TREATMENT PLAN, INITIAL ASSESSMENT 27446-4 CARDIAC REHABILITATION TREATMENT PLAN, PLAN OF TREATMENT 27447-2 CARDIAC REHABILITATION TREATMENT PLAN, PROGRESS NOTE + ATTAINMENT

OF GOALS 27448-0 CARDIAC REHABILITATION TREATMENT PLAN, REASON T O CONTINUE 27449-8 CARDIAC REHABILITATION TREATMENT PLAN, JUSTIFICATION


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LOINC Code Description 27764-0 MEDICAL SOCIAL SERVICES TREATMENT PLAN, DATE RANGE (FROM/THROUGH)

OF HOSPITALIZATION LEADING TO TREATMENT 27765-7 MEDICAL SOCIAL SERVICES TREATMENT PLAN, CONTINUATION STATUS 27766-5 MEDICAL SOCIAL SERVICES TREATMENT PLAN, DATE ATTENDING MD REFERRED

PATIENT FOR TREATMENT 27767-3 MEDICAL SOCIAL SERVICES TREATMENT PLAN, DATE ATTENDING MD SIGNED 27768-1 MEDICAL SOCIAL SERVICES TREATMENT PLAN, DATE MEDICAL SOCIAL SERVICES

PROFESSIONAL SIGNED 27769-9 MEDICAL SOCIAL SERVICES TREATMENT PLAN, SIGNATURE OF RESPONSIBLE

ATTENDING MD ON FILE 27770-7 MEDICAL SOCIAL SERVICES TREATMENT PLAN, SIGNATURE OF RESPONSIBLE

MEDICAL SOCIAL SERVICES PROFESSIONAL ON FILE 27771-5 MEDICAL SOCIAL SERVICES TREATMENT PLAN, MEDICATION ADMINISTERED 27772-3 MEDICAL SOCIAL SERVICES TREATMENT PLAN, PROGNOSIS FOR MEDICAL SOCIAL

SERVICES 27773-1 MEDICAL SOCIAL SERVICES TREATMENT PLAN, ESTIMATED DATE OF

COMPLETION 27774-9 MEDICAL SOCIAL SERVICES TREATMENT PLAN, DATE OF LAST PLAN OF

TREATMENT CERTIFICATION 27775-6 MEDICAL SOCIAL SERVICES TREATMENT PLAN, PAST MEDICAL HISTORY + LEVEL

OF FUNCTION 27776-4 MEDICAL SOCIAL SERVICES TREATMENT PLAN, INITIAL ASSESSMENT 27777-2 MEDICAL SOCIAL SERVICES TREATMENT PLAN, PLAN OF TREATMENT 27778-0 MEDICAL SOCIAL SERVICES TREATMENT PLAN, PROGRESS NOTE + ATTAINMENT

OF GOALS 27779-8 MEDICAL SOCIAL SERVICES TREATMENT PLAN, REASON TO CONTINUE 27780-6 MEDICAL SOCIAL SERVICES TREATMENT PLAN, JUSTIFICATION

2.4.4 Occupational Therapy Rehabilitation Attachment

Table 2.4.4 Data Components for Occupational Therapy Rehabilitation Attachment

LOINC Code Description 18826-8 OCCUPATIONAL THERAPY REHABILITATION ATTACHMENT

27597-4 OCCUPATIONAL THERAPY TREATMENT PLAN, NEW/REVISED 27598-2 OCCUPATIONAL THERAPY TREATMENT PLAN, DATE ONSET OR EXACERBATION OF

PRIMARY DIAGNOSIS 27472-0 OCCUPATIONAL THERAPY TREATMENT PLAN, START DATE 27635-2 OCCUPATIONAL THERAPY TREATMENT PLAN, PRIMARY DIAGNOSIS 27601-4 OCCUPATIONAL THERAPY TREATMENT PLAN, DIAGNOSIS ADDRESSED BY PLAN 27602-2 OCCUPATIONAL THERAPY TREATMENT PLAN, AUTHOR OF TREATMENT PLAN 27606-3 OCCUPATIONAL THERAPY TREATMENT PLAN, VISIT FREQUENCY 27608-9 OCCUPATIONAL THERAPY TREATMENT PLAN, DATE RANGE (FROM/THROUGH)

DESCRIBED BY PLAN 27611-3 OCCUPATIONAL THERAPY TREATMENT PLAN, DATE RANGE (FROM/THROUGH) OF

HOSPITALIZATION LEADING TO TREATMENT 27612-1 OCCUPATIONAL THERAPY TREATMENT PLAN, CONTINUATION STATUS 27613-9 OCCUPATIONAL THERAPY TREATMENT PLAN, DATE ATTENDING MD REFERRED

PATIENT FOR TREATMENT 27614-7 OCCUPATIONAL THERAPY TREATMENT PLAN, DATE ATTENDING MD SIGNED 27615-4 OCCUPATIONAL THERAPY TREATMENT PLAN, DATE OCCUPATIONAL THERAPY

PROFESSIONAL SIGNED 27616-2 OCCUPATIONAL THERAPY TREATMENT PLAN, SIGNATURE OF RESPONSIBLE

ATTENDING MD ON FILE 27617-0 OCCUPATIONAL THERAPY TREATMENT PLAN, SIGNATURE OF RESPONSIBLE

OCCUPATIONAL THERAPY PROFESSIONAL ON FILE 27618-8 OCCUPATIONAL THERAPY TREATMENT PLAN, MEDICATION ADMINISTERED 27619-6 OCCUPATIONAL THERAPY TREATMENT PLAN, PROGNOSIS FOR OCCUPATIONAL

THERAPY 27620-4 OCCUPATIONAL THERAPY TREATMENT PLAN, ESTIMATED DATE OF COMPLETION



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LOINC Code Description 27621-2 OCCUPATIONAL THERAPY TREATMENT PLAN, DATE OF LAST PLAN OF

TREATMENT CERTIFICATION 27622-0 OCCUPATIONAL THERAPY TREATMENT PLAN, PAST MEDICAL HISTORY + LEVEL

OF FUNCTION 27623-8 OCCUPATIONAL THERAPY TREATMENT PLAN, INITIAL ASSESSMENT 27624-6 OCCUPATIONAL THERAPY TREATMENT PLAN, PLAN OF TREATMENT 27625-3 OCCUPATIONAL THERAPY TREATMENT PLAN, PROGRESS NOTE + ATTAINMENT OF

GOALS 27626-1 OCCUPATIONAL THERAPY TREATMENT PLAN, REASON TO CONTINUE 27627-9 OCCUPATIONAL THERAPY TREATMENT PLAN, JUSTIFICATION

2.4.5 Physical Therapy Rehabilitation Attachment

Table 2.4.5 Data Components for Physical Therapy Rehabilitation Attachment LOINC Code Description 19002-5 PHYSICAL THERAPY REHABILITATION ATTACHMENT

27660-0 PHYSICAL THERAPY TREATMENT PLAN, NEW/REVISED 27661-8 PHYSICAL THERAPY TREATMENT PLAN, DATE ONSET OR EXACERBATION OF

PRIMARY DIAGNOSIS 27662-6 PHYSICAL THERAPY TREATMENT PLAN, START DATE 27698-0 PHYSICAL THERAPY TREATMENT PLAN, PRIMARY DIAGNOSIS 27664-2 PHYSICAL THERAPY TREATMENT PLAN, DIAGNOSIS ADDRESSED BY PLAN 27665-9 PHYSICAL THERAPY TREATMENT PLAN, AUTHOR OF TREATMENT PLAN 27669-1 PHYSICAL THERAPY TREATMENT PLAN, VISIT FREQUENCY 27671-7 PHYSICAL THERAPY TREATMENT PLAN, DATE RANGE (FROM/THROUGH)

DESCRIBED BY PLAN 27674-1 PHYSICAL THERAPY TREATMENT PLAN, DATE RANGE (FROM/THROUGH) OF

HOSPITALIZATION LEADING TO TREATMENT 27675-8 PHYSICAL THERAPY TREATMENT PLAN, CONTINUATION STATUS 27676-6 PHYSICAL THERAPY TREATMENT PLAN, DATE ATTENDING MD REFERRED PATIENT

FOR TREATMENT 27677-4 PHYSICAL THERAPY TREATMENT PLAN, DATE ATTENDING MD SIGNED 27678-2 PHYSICAL THERAPY TREATMENT PLAN, DATE PHYSICAL THERAPY PROFESSIONAL

SIGNED 27679-0 PHYSICAL THERAPY TREATMENT PLAN, SIGNATURE OF RESPONSIBLE ATTENDING

MD ON FILE 27680-8 PHYSICAL THERAPY TREATMENT PLAN, SIGNATURE OF RESPONSIBLE PHYSICAL

THERAPY PROFESSIONAL ON FILE 27681-6 PHYSICAL THERAPY TREATMENT PLAN, MEDICATION ADMINISTERED 27682-4 PHYSICAL THERAPY TREATMENT PLAN, PROGNOSIS FOR PHYSICAL THERAPY 27683-2 PHYSICAL THERAPY TREATMENT PLAN, ESTIMATED DATE OF COMPLETION 27684-0 PHYSICAL THERAPY TREATMENT PLAN, DATE OF LAST PLAN OF TREATMENT

CERTIFICATION 27685-7 PHYSICAL THERAPY TREATMENT PLAN, PAST MEDICAL HISTORY + LEVEL OF

FUNCTION 27686-5 PHYSICAL THERAPY TREATMENT PLAN, INITIAL ASSESSMENT 27687-3 PHYSICAL THERAPY TREATMENT PLAN, PLAN OF TREATMENT 27688-1 PHYSICAL THERAPY TREATMENT PLAN, PROGRESS NOTE + ATTAINMENT OF

GOALS 27689-9 PHYSICAL THERAPY TREATMENT PLAN, REASON TO CONTINUE 27690-7 PHYSICAL THERAPY TREATMENT PLAN, JUSTIFICATION


Page 10 May 2004


2.4.6 Psychiatric Rehabilitation Attachment

Table 2.4.6 Data Components for Psychiatric Rehabilitation Attachment

2.4.7 Respiratory Therapy Rehabilitation Attachment

Table 2.4.7 Data Components for Respiratory Therapy Rehabilitation Attachment

LOINC Code Description 19003-3 RESPIRATORY THERAPY REHABILITATION ATTACHMENT

27699-8 RESPIRATORY THERAPY TREATMENT PLAN, NEW/REVISED 27700-4 RESPIRATORY THERAPY TREATMENT PLAN, DATE ONSET OR EXACERBATION OF

PRIMARY DIAGNOSIS 27701-2 RESPIRATORY THERAPY TREATMENT PLAN, START DATE

LOINC Code Description 18594-2 PSYCHIATRIC REHABILITATION ATTACHMENT

18626-2 PSYCHIATRIC REHABILITATION TREATMENT PLAN, NEW/REVISED 18627-0 PSYCHIATRIC REHABILITATION TREATMENT PLAN, DATE ONSET OR

EXACERBATION OF PRIMARY DIAGNOSIS 18628-8 PSYCHIATRIC REHABILITATION TREATMENT PLAN, START DATE 19007-4 PSYCHIATRIC REHABILITATION TREATMENT PLAN, PRIMARY DIAGNOSIS 18631-2 PSYCHIATRIC REHABILITATION TREATMENT PLAN, DIAGNOSIS ADDRESSED BY

PLAN 18632-0 PSYCHIATRIC REHABILITATION TREATMENT PLAN, AUTHOR OF TREATMENT

PLAN 18637-9 PSYCHIATRIC REHABILITATION TREATMENT PLAN, VISIT FREQUENCY 18639-5 PSYCHIATRIC REHABILITATION TREATMENT PLAN, DATE RANGE

(FROM/THROUGH) DESCRIBED BY PLAN 18642-9 PSYCHIATRIC REHABILITATION TREATMENT PLAN, DATE RANGE

(FROM/THROUGH) OF HOSPITALIZATION LEADING TO TREATMENT 18645-2 PSYCHIATRIC REHABILITATION TREATMENT PLAN, CONTINUATION STATUS 18646-0 PSYCHIATRIC REHABILITATION TREATMENT PLAN, DATE ATTENDING MD

REFERRED PATIENT FOR TREATMENT 18647-8 PSYCHIATRIC REHABILITATION TREATMENT PLAN, DATE ATTENDING MD

SIGNED 18648-6 PSYCHIATRIC REHABILITATION TREATMENT PLAN, DATE REHAB PROFESSIONAL

SIGNED 18649-4 PSYCHIATRIC REHABILITATION TREATMENT PLAN, SIGNATURE OF RESPONSIBLE

ATTENDING MD ON FILE 18650-2 PSYCHIATRIC REHABILITATION TREATMENT PLAN, SIGNATURE OF RESPONSIBLE

REHAB PROFESSIONAL ON FILE 18651-0 PSYCHIATRIC REHABILITATION TREATMENT PLAN, MEDICATION ADMINISTERED 18652-8 PSYCHIATRIC REHABILITATION TREATMENT PLAN, PROGNOSIS FOR

REHABILITATION 18653-6 PSYCHIATRIC REHABILITATION TREATMENT PLAN, ESTIMATED DATE OF

COMPLETION 18654-4 PSYCHIATRIC REHABILITATION TREATMENT PLAN, DATE OF LAST PLAN OF

TREATMENT CERTIFICATION 18655-1 PSYCHIATRIC REHABILITATION TREATMENT PLAN, PAST MEDICAL HISTORY +

LEVEL OF FUNCTION 18656-9 PSYCHIATRIC REHABILITATION TREATMENT PLAN, INITIAL ASSESSMENT 18657-7 PSYCHIATRIC REHABILITATION TREATMENT PLAN, PLAN OF TREATMENT 18658-5 PSYCHIATRIC REHABILITATION TREATMENT PLAN, PROGRESS NOTE +

ATTAINMENT OF GOALS 18659-3 PSYCHIATRIC REHABILITATION TREATMENT PLAN, REASON TO CONTINUE 18660-1 PSYCHIATRIC REHABILITATION TREATMENT PLAN, JUSTIFICATION 18661-9 PSYCHIATRIC REHABILITATION TREATMENT PLAN, PSYCHIATRIC SYMPTOMS



Page 11 May 2004

LOINC Code Description 27740-0 RESPIRATORY THERAPY TREATMENT PLAN, PRIMARY DIAGNOSIS 27703-8 RESPIRATORY THERAPY TREATMENT PLAN, DIAGNOSIS ADDRESSED BY PLAN 27704-6 RESPIRATORY THERAPY TREATMENT PLAN, AUTHOR OF TREATMENT PLAN 27708-7 RESPIRATORY THERAPY TREATMENT PLAN, VISIT FREQUENCY 27710-3 RESPIRATORY THERAPY TREATMENT PLAN, DATE RANGE (FROM/THROUGH)

DESCRIBED BY PLAN 27713-7 RESPIRATORY THERAPY TREATMENT PLAN, DATE RANGE (FROM/THROUGH) OF

HOSPITALIZATION LEADING TO TREATMENT 27714-5 RESPIRATORY THERAPY TREATMENT PLAN, CONTINUATION STATUS 27715-2 RESPIRATORY THERAPY TREATMENT PLAN, DATE ATTENDING MD REFERRED

PATIENT FOR 27716-0 RESPIRATORY THERAPY TREATMENT PLAN, DATE ATTENDING MD SIGNED 27717-8 RESPIRATORY THERAPY TREATMENT PLAN, DATE RESPIRATORY THERAPY

PROFESSIONAL SIGNED 27718-6 RESPIRATORY THERAPY TREATMENT PLAN, SIGNATURE OF RESPONSIBLE

ATTENDING MD ON FILE 27719-4 RESPIRATORY THERAPY TREATMENT PLAN, SIGNATURE OF RESPONSIBLE

RESPIRATORY THERAPY PROFESSIONAL ON FILE 27720-2 RESPIRATORY THERAPY TREATMENT PLAN, MEDICATION ADMINISTERED 27721-0 RESPIRATORY THERAPY TREATMENT PLAN, PROGNOSIS FOR RESPIRATORY

THERAPY 27722-8 RESPIRATORY THERAPY TREATMENT PLAN, ESTIMATED DATE OF COMPLETION 27723-6 RESPIRATORY THERAPY TREATMENT PLAN, DATE OF LAST PLAN OF TREATMENT

CERTIFICATION 27724-4 RESPIRATORY THERAPY TREATMENT PLAN, PAST MEDICAL HISTORY + LEVEL OF

FUNCTION 27725-1 RESPIRATORY THERAPY TREATMENT PLAN, INITIAL ASSESSMENT 27726-9 RESPIRATORY THERAPY TREATMENT PLAN, PLAN OF TREATMENT 27727-7 RESPIRATORY THERAPY TREATMENT PLAN, PROGRESS NOTE + ATTAINMENT OF

GOALS 27728-5 RESPIRATORY THERAPY TREATMENT PLAN, REASON TO CONTINUE 27729-3 RESPIRATORY THERAPY TREATMENT PLAN, JUSTIFICATION

2.4.8 Skilled Nursing Rehabilitation Attachment

Table 2.4.8 Data Components for Skilled Nursing Rehabilitation Attachment

LOINC Code Description 19004-1 SKILLED NURSING REHABILITATION ATTACHMENT

27470-4 SKILLED NURSING TREATMENT PLAN, NEW/REVISED 27471-2 SKILLED NURSING TREATMENT PLAN, DATE ONSET OR EXACERBATION OF

PRIMARY DIAGNOSIS 27472-0 SKILLED NURSING TREATMENT PLAN, START DATE 27587-5 SKILLED NURSING TREATMENT PLAN, PRIMARY DIAGNOSIS 27550-3 SKILLED NURSING TREATMENT PLAN, DIAGNOSIS ADDRESSED BY PLAN 27551-1 SKILLED NURSING TREATMENT PLAN, AUTHOR OF TREATMENT PLAN 27555-2 SKILLED NURSING TREATMENT PLAN, VISIT FREQUENCY 27557-8 SKILLED NURSING TREATMENT PLAN, DATE RANGE (FROM/THROUGH) DESCRIBED

BY PLAN 27560-2 SKILLED NURSING TREATMENT PLAN, DATE RANGE (FROM/THROUGH) OF

HOSPITALIZATION LEADING TO TREATMENT 27561-0 SKILLED NURSING TREATMENT PLAN, CONTINUATION STATUS 27562-8 SKILLED NURSING TREATMENT PLAN, DATE ATTENDING MD REFERRED PATIENT

FOR TREATMENT 27563-6 SKILLED NURSING TREATMENT PLAN, DATE ATTENDING MD SIGNED 27564-4 SKILLED NURSING TREATMENT PLAN, DATE SKILLED NURSING PROFESSIONAL

SIGNED 27565-1 SKILLED NURSING TREATMENT PLAN, SIGNATURE OF RESPONSIBLE ATTENDING

MD ON FILE


Page 12 May 2004


LOINC Code Description 27566-9 SKILLED NURSING TREATMENT PLAN, SIGNATURE OF RESPONSIBLE SKILLED

NURSING PROFESSIONAL ON FILE 27567-7 SKILLED NURSING TREATMENT PLAN, MEDICATION ADMINISTERED 27568-5 SKILLED NURSING TREATMENT PLAN, PROGNOSIS FOR SKILLED NURSING 27569-3 SKILLED NURSING TREATMENT PLAN, ESTIMATED DATE OF COMPLETION 27570-1 SKILLED NURSING TREATMENT PLAN, DATE OF LAST PLAN OF TREATMENT

CERTIFICATION 27571-9 SKILLED NURSING TREATMENT PLAN, PAST MEDICAL HISTORY + LEVEL OF

FUNCTION 27572-7 SKILLED NURSING TREATMENT PLAN, INITIAL ASSESSMENT 27573-5 SKILLED NURSING TREATMENT PLAN, PLAN OF TREATMENT 27574-3 SKILLED NURSING TREATMENT PLAN, PROGRESS NOTE + ATTAINMENT OF GOALS 27575-0 SKILLED NURSING TREATMENT PLAN, REASON TO CONTINUE 27576-8 SKILLED NURSING TREATMENT PLAN, JUSTIFICATION

2.4.9 Speech Therapy Rehabilitation Attachment

Table 2.4.9 Data Components for Speech Therapy Rehabilitation Attachment

LOINC Code Description 29206-0 SPEECH THERAPY REHABILITATION ATTACHMENT

29162-5 SPEECH THERAPY TREATMENT PLAN, NEW/REVISED 29163-3 SPEECH THERAPY TREATMENT PLAN, DATE ONSET OR EXACERBATION OF

PRIMARY DIAGNOSIS 29164-1 SPEECH THERAPY TREATMENT PLAN, START DATE 29166-6 SPEECH THERAPY TREATMENT PLAN, PRIMARY DIAGNOSIS 29167-4 SPEECH THERAPY TREATMENT PLAN, DIAGNOSIS ADDRESSED BY PLAN 29168-2 SPEECH THERAPY TREATMENT PLAN, AUTHOR OF TREATMENT PLAN 29169-0 SPEECH THERAPY TREATMENT PLAN, VISIT FREQUENCY 29170-8 SPEECH THERAPY TREATMENT PLAN, DATE RANGE (FROM/THROUGH) DESCRIBED

BY PLAN 29203-7 SPEECH THERAPY TREATMENT PLAN, DATE RANGE (FROM/THROUGH) OF

HOSPITALIZATION LEADING TO TREATMENT 29171-6 SPEECH THERAPY TREATMENT PLAN, CONTINUATION STATUS 29172-4 SPEECH THERAPY TREATMENT PLAN, DATE ATTENDING MD REFERRED PATIENT

FOR TREATMENT 29173-2 SPEECH THERAPY TREATMEN T PLAN, DATE ATTENDING MD SIGNED 29175-7 SPEECH THERAPY TREATMENT PLAN, DATE SPEECH THERAPY PROFESSIONAL

SIGNED 29174-0 SPEECH THERAPY TREATMENT PLAN, SIGNATURE OF RESPONSIBLE ATTENDING

MD ON FILE 29176-5 SPEECH THERAPY TREATMENT PLAN, SIGNATURE OF RESPONSIBLE SPEECH

THERAPY PROFESSIONAL ON FILE 29177-3 SPEECH THERAPY TREATMENT PLAN, MEDICATION ADMINISTERED 29178-1 SPEECH THERAPY TREATMENT PLAN, PROGNOSIS FOR THERAPY 29179-9 SPEECH THERAPY TREATMENT PLAN, ESTIMATED DATE OF COMPLETION 29180-7 SPEECH THERAPY TREATMENT PLAN, DATE OF LAST PLAN OF TREATMENT

CERTIFICATION 29181-5 SPEECH THERAPY TREATMENT PLAN, PAST MEDICAL HISTORY + LEVEL OF

FUNCTION 29182-3 SPEECH THERAPY TREATMENT PLAN, INITIAL ASSESSMENT 29183-1 SPEECH THERAPY TREATMENT PLAN, PLAN OF TREATMENT 29184-9 SPEECH THERAPY TREATMENT PLAN, PROGRESS NOTE + ATTAINMENT OF GOALS 29185-6 SPEECH THERAPY TREATMENT PLAN, REASON TO CONTINUE 29186-4 SPEECH THERAPY TREATMENT PLAN, JUSTIFICATION



Page 13 May 2004

3 Rehabilitation Services Attachment Value Tables Each of the tables in this section further describes the LOINC components listed in the above corresponding table, along with the expected answer part(s) for each question, including the data type, cardinality, and codes/units for each answer. The minimum attachment data set equates to the required components; those identified in the value table, below, with cardinality (Card) of

{1,1} (component is required and has one and only one occurrence) or {1,n} (component is required and has one or more occurrences).

Those data components with a cardinality of {0,1} (if available has one and only one occurrence) or {0,n} (if available may have one or more occurrences) shall be sent if available.

3.1 Alcohol-Substance Abuse Rehabilitation Service Value Table

Table 3.1 Alcohol-Substance Abuse Rehabilitation Service Value Table LOINC code

Component Answer Value Data

Type Card Response Code

/ Numeric Units 27474-6 ALCOHOL-SUBSTANCE ABUSE

REHABILITATION TREATMENT PLAN, NEW/REVISED

1,1

27474-6 700 original 701 updated See section 5 for the list of valid codes.

CE 1,1 HL79002

27801-0 ALCOHOL-SUBSTANCE ABUSE REHABILITATION TREATMENT PLAN, DATE ONSET OR EXACERBATION OF PRIMARY DIAGNOSIS

1,1

27801-0

DT 1,1

27475-3 ALCOHOL-SUBSTANCE ABUSE REHABILITATION TREATMENT PLAN, START DATE

1,1

27475-3

DT 1,1

27515-6 ALCOHOL-SUBSTANCE ABUSE REHABILITATION TREATMENT PLAN, PRIMARY DIAGNOSIS

1,1

27515-6 ALCOHOL-SUBSTANCE ABUSE REHABILITATION TREATMENT PLAN, PRIMARY DIAGNOSIS (IDENTIFIER) ICD-9CM code.

CE 1,1 I9C

27477-9 ALCOHOL-SUBSTANCE ABUSE REHABILITATION TREATMENT PLAN, DIAGNOSIS ADDRESSED BY PLAN

1,1

27477-9 ALCOHOL-SUBSTANCE ABUSE REHABILITATION TREATMENT PLAN, DIAGNOSIS ADDRESSED BY PLAN (IDENTIFIER) ICD-9CM code.

CE 1,1 I9C


Page 14 May 2004


LOINC code Component Answer

Value Data Type

Card Response Code / Numeric Units

27478-7 ALCOHOL-SUBSTANCE ABUSE REHABILITATION TREATMENT PLAN, AUTHOR OF TREATMENT PLAN (COMPOSITE)

1,1

27479-5 ALCOHOL-SUBSTANCE ABUSE REHABILITATION TREATMENT PLAN, AUTHOR NAME

PN 1,1

27514-9 ALCOHOL-SUBSTANCE ABUSE REHABILITATION TREATMENT PLAN, AUTHOR IDENTIFIER Unique identifier for the professional who established the treatment plan. At some point use of the National Provider Identifier (NPI) will be mandated, until such time other identifiers such as UPIN or state license number are allowed. Note: The @ S attribute will indicate the authority assigning the identifier; for example, NPI, UPIN, or XX, where XX is the two-letter US Postal Service abbreviation for the state of the licensing authority.

CX 1,1 See note at left.

27480-3 ALCOHOL-SUBSTANCE ABUSE REHABILITATION TREATMENT PLAN, AUTHOR PROFESSION As described by the Health Care Provider Taxonomy.

CE 0,1 PTX

27482-9 ALCOHOL-SUBSTANCE ABUSE REHABILITATION TREATMENT PLAN, VISIT FREQUENCY

1,1

27482-9

TQ 1,1

27487-8 ALCOHOL-SUBSTANCE ABUSE REHABILITATION TREATMENT PLAN, DATE RANGE (FROM/THROUGH) DESCRIBED BY PLAN (COMPOSITE)

1,1

27488-6 ALCOHOL-SUBSTANCE ABUSE REHABILITATION TREATMENT PLAN, PLAN START DATE

DT 1,1

27489-4 ALCOHOL-SUBSTANCE ABUSE REHABILITATION TREATMENT PLAN, PLAN END DATE

DT

1,1

27490-2 ALCOHOL-SUBSTANCE ABUSE REHABILITATION TREATMENT PLAN, DATE RANGE (FROM/THROUGH) OF HOSPITALIZATION LEADING TO TREATMENT (COMPOSITE)

0,1

27516-4 ALCOHOL-SUBSTANCE ABUSE REHABILITATION TREATMENT PLAN, STA RT DATE OF HOSPITALIZATION LEADING TO TREATMENT

DT 1,1

27517-2 ALCOHOL-SUBSTANCE ABUSE REHABILITATION TREATMENT PLAN, END DATE OF HOSPITALIZATION LEADING TO TREATMENT

DT 1,1



Page 15 May 2004


Value Data Type


27491-0 ALCOHOL-SUBSTANCE ABUSE REHABILITATION TREATMENT PLAN, CONTINUATION STATUS

1,1

27491-0 C continue D discontinue

CE 1,1 HL79003

27492-8 ALCOHOL-SUBSTANCE ABUSE REHABILITATION TREATMENT, DATE ATTENDING MD REFERRED PATIENT FOR TREATMENT

0,1

27492-8

DT 1,1

27493-6 ALCOHOL-SUBSTANCE ABUSE REHABILITATION TREATMENT PLAN, DATE ATTENDING MD SIGNED

0,1

27493-6 DT 1,1 27494-4 ALCOHOL-SUBSTANCE ABUSE

REHABILITATION TREATMENT PLAN, DATE REHAB PROFESSIONAL SIGNED

1,1

27494-4 DT 1,1 27495-1 ALCOHOL-SUBSTANCE ABUSE

REHABILITATION TREATMENT PLAN, SIGNATURE OF RESPONSIB LE ATTENDING MD ON FILE

0,1

27495-1 N No Y Yes

CE 1,1 HL70136

27496-9 ALCOHOL-SUBSTANCE ABUSE REHABILITATION TREATMENT PLAN, SIGNATURE OF RESPONSIBLE REHAB PROFESSIONAL ON FILE

1,1

27496-9 N No Y Yes

CE 1,1 HL70136


Page 16 May 2004



Value Data Type


27498-5 ALCOHOL-SUBSTANCE ABUSE REHABILITATION TREATMENT PLAN, MEDICATION ADMINISTERED (COMPOSITE) Repeat the components as needed to report all medications administered as past of the rehabilitation treatment plan within the dates of service of the associated claim or for the period defined by the modifier codes. For additional details, see CDAR1AIS0006R021 Additional Information Specification 0006: Medications Attachment.

0,n

27524-8 ALCOHOL-SUBSTANCE ABUSE REHABILITATION TREATMENT PLAN, MEDICATION NAME + IDENTIFIER NDC number and text preferred or just text. To affirmatively document that none were administered use the "No Information" data type.

CE 1,1 See note at left NDC (preferred)

27525-5 ALCOHOL-SUBSTANCE ABUSE REHABILITATION TREATMENT PLAN, MEDICATION DOSE Supplement verbal information in the <content> element when units are complex or determined as unit per time.

NM 1,1 iso+

27526-3

ALCOHOL-SUBSTANCE ABUSE REHABILITATION TREATMENT PLAN, MEDICATION TIMING + QUANTITY

TQ 1,1

27537-0 ALCOHOL-SUBSTANCE ABUSE REHABILITATION TREATMENT PLAN, MEDICATION ROUTE See section 5 for the list of valid codes.

CE 1,1 HL70162

27499-3 ALCOHOL-SUBSTANCE ABUSE REHABILITATION TREATMENT PLAN, PROGNOSIS FOR REHABILITATION

1,1

27499-3 1 Poor 2 Guarded 3 Fair 4 Good 5 Excellent

CE 1,1 HL79005

27500-8 ALCOHOL-SUBSTANCE ABUSE REHABILITATION TREATMENT PLAN, ESTIMATED DATE OF COMPLETION

1,1

27500-8

DT 1,1

27501-6 ALCOHOL-SUBSTANCE ABUSE REHABILITATION TREATMENT PLAN, DATE OF LAST PLAN OF TREATMENT CERTIFICATION

0,1

27501-6

DT 1,1



Page 17 May 2004


Value Data Type


27502-4 ALCOHOL-SUBSTANCE ABUSE REHABILITATION TREATMENT PLAN, PAST MEDICAL HISTORY + LEVEL OF FUNCTION (NARRATIVE)

1,1

27502-4

TX 1,1

27503-2 ALCOHOL-SUBSTANCE ABUSE REHABILITATION TREATMENT PLAN, INITIAL ASSESSMENT (NARRATIVE)

1,1

27503-2

TX 1,1

27504-0 ALCOHOL-SUBSTANCE ABUSE REHABILITATION TREATMENT PLAN, PLAN OF TREATMENT (NARRATIVE)

1,1

27504-0

TX 1,1

27505-7 ALCOHOL-SUBSTANCE ABUSE REHABILITATION TREATMENT PLAN, PROGRESS NOTE + ATTAINMENT OF GOALS (NARRATIVE)

1,1

27505-5

TX 1,1

27506-5 ALCOHOL-SUBSTANCE ABUSE REHABILITATION TREATMENT PLAN, REASON TO CONTINUE (NARRATIVE)

0,1

27506-5

TX 1,1

27507-3 ALCOHOL-SUBSTANCE ABUSE REHABILITATION TREATMENT PLAN, JUSTIFICATION (NARRATIVE)

0,1

27507-3

TX 1,1

18662-7 ALCOHOL-SUBSTANCE ABUSE REHABILITATION TREATMENT PLAN, CHIEF COMPLAINT+REASON FOR REFERRAL+REASON FOR RELAPSE IF KNOWN (NARRATIVE)

0,1

18662-7

TX 1,1

18663-5 ALCOHOL-SUBSTANCE ABUSE REHABILITATION TREATMENT PLAN, HISTORY OF PRESENT ALCOHOL/SUBSTANCE ABUSE (NARRATIVE)

1,1

18663-5

TX 1,1


Page 18 May 2004



Value Data Type


18664-3 ALCOHOL-SUBSTANCE ABUSE REHABILITATION TREATMENT PLAN, FOLLOWUP APPROACH (COMPOSITE)

0,1

18665-0 ALCOHOL-SUBSTANCE ABUSE REHABILITATION TREATMENT PLAN, AGENCY THAT WILL FOLLOW UP Provider may respond with agency or person. If both are sent, the person should be affiliated with the agency.

ST 0,1

18666-8 ALCOHOL-SUBSTANCE ABUSE REHABILITATION TREATMENT PLAN, PERSON THAT WILL FOLLOW UP Provider may responds with agency or person. If both sent, the person should be affiliated with the agency.

PN 0,1

18667-6 ALCOHOL-SUBSTANCE ABUSE REHABILITATION TREATMENT PLAN, METHODOLOGY FOR FOLLOW UP

TX 1,1

18668-4

ALCOHOL-SUBSTANCE ABUSE REHABILITATION TREATMENT PLAN, FREQUENCY OF ASSESSMENTS FOR FOLLOW UP

TQ 1,1

18669-2 ALCOHOL-SUBSTANCE ABUSE REHABILITATION TREATMENT PLAN, LEVEL OF PATIENT PARTICIPATION

1,1

18669-2

ST 1,1

27513-1 ALCOHOL-SUBSTANCE ABUSE REHABILITATION TREATMENT PLAN, DATE RANGE (FROM/THROUGH) OF NEXT PLANNED TREATMENT (COMPOSITE)

0,1

27488-6 ALCOHOL-SUBSTANCE ABUSE REHABILITATION TREATMENT PLAN, NEXT PLANNED TREATMENT START DATE

DT 1,1

27489-4 ALCOHOL-SUBSTANCE ABUSE REHABILITATION TREATMENT PLAN, NEXT PLANNED TREATMENT END DATE

DT 1,1

18671-8 ALCOHOL-SUBSTANCE ABUSE REHABILITATION TREATMENT PLAN, NEXT PLAN OF TREATMENT TEXT (NARRATIVE)

0,1

18671-8

TX 1,1

18672-6 ALCOHOL-SUBSTANCE ABUSE REHABILITATION TREATMENT PLAN, ALCOHOL/SUBSTANCE ABUSE SYMPTOMS WITH PHYSIOLOGICAL DEPENDENCE INDICATOR

1,1

18672-6 N No Y Yes

CE 1,1 HL70136



Page 19 May 2004


Value Data Type


18673-4 ALCOHOL-SUBSTANCE ABUSE REHABILITATION TREATMENT PLAN, REHABILITATION PROBLEM REMISSION STATUS

1,1

18673-4 1 Early Full Remission 2 Early Partial Remission 3 Sustained Full Remission 4 Sustained Partial Remission

CE 1,1 HL79006

18674-2 ALCOHOL-SUBSTANCE ABUSE REHABILITATION TREATMENT PLAN, LONGEST PERIOD OF SOBRIETY FOR ABUSED SUBSTANCE (COMPOSITE)

0,n

18675-9 ALCOHOL-SUBSTANCE ABUSE REHABILITATION TREATMENT PLAN, ABUSED SUBSTANCE

ST 1,1

18676-7 ALCOHOL-SUBSTANCE ABUSE REHABILITATION TREATMENT PLAN, LONGEST PERIOD OF SOBRIETY Include units for the period of sobriety: days, months, or weeks.

NM 1,1 iso+

3.2 Cardiac Rehabilitation Service Value Table

Table 3.2 Cardiac Rehabilitation Service Value Table LOINC code



/ Numeric Units 27483-7 CARDIAC REHABILITATION TREATMENT PLAN,

NEW/REVISED 1,1

27483-7 700 original 701 updated

CE 1,1 HL79002

27484-5 CARDIAC REHABILITATION TREATMENT PLAN, DATE ONSET OR EXACERBATION OF PRIMARY DIAGNOSIS

1,1

27484-5 DT 1,1 27485-2 CARDIAC REHABILITATION TREATMENT PLAN,

START DATE 1,1


PRIMARY DIAGNOSIS 1,1

27457-1 CARDIAC REHABILITATION TREATMENT PLAN, PRIMARY DIAGNOSIS (IDENTIFIER) ICD-9CM code.

CE 1,1 I9C

27518-0 CARDIAC REHABILITATION TREATMENT PLAN, DIAGNOSIS ADDRESSED BY PLAN

1,1

27518-0 CARDIAC REHABILITATION TREATMENT PLAN, DIAGNOSIS ADDRESSED BY PLAN (IDENTIFIER) ICD-9CM code.

CE 1,1 I9C


Page 20 May 2004



Value Data Type


27519-8 CARDIAC REHABILITATION TREATMENT PLAN, AUTHOR OF TREATMENT PLAN (COMPOSITE)

1,1

27520-6 CARDIAC REHABILITATION TREATMENT PLAN, AUTHOR NAME

PN 1,1

27456-3 CARDIAC REHABILITATION TREATMENT PLAN, AUTHOR IDENTIFIER Unique identifier for the professional who established the treatment plan. At some point use of the National Provider Identifier (NPI) will be mandated, until such time other identifiers such as UPIN or state license number are allowed. Note: The @ S attribute will indicate the authority assigning the identifier; for example, NPI, UPIN, or XX, where XX is the two-letter US Postal Service abbreviation for the state of the licensing authority.

CX 1,1 See note at left

27521-4 CARDIAC REHABILITATION TREATMENT PLAN, AUTHOR PROFESSION As described by the Health Care Provider Taxonomy.

CE 0,1 PTX

27531-3 CARDIAC REHABILITATION TREATMENT PLAN, VISIT FREQUENCY

1,1

27531-3

TQ 1,1

27533-9 CARDIAC REHABILITATION TREATMENT PLAN, DATE RANGE (FROM/THROUGH) DESCRIBED BY PLAN (COMPOSITE)

1,1

27534-7 CARDIAC REHABILITATION TREATMENT PLAN, PLAN START DATE

DT 1,1

27535-4 CARDIAC REHABILITATION TREATMENT PLAN, PLAN END DATE

DT 1,1

27536-2 CARDIAC REHABILITATION TREATMENT PLAN, DATE RANGE (FROM/THROUGH) OF HOSPITALIZATION LEADING TO TREATMENT (COMPOSITE)

0,1

27458-9 CARDIAC REHABILITATION TREATMENT PLAN, START DATE OF HOSPITALIZATION LEADING TO TREATMENT

DT 1,1

27459-7 CARDIAC REHABILITATION TREATMENT PLAN, END DATE OF HOSPITALIZATION LEADING TO TREATMENT

DT 1,1

27539-2 CARDIAC REHABILITATION TREATMENT PLAN, CONTINUATION STATUS

1,1


CE 1,1 HL79003

27540-4 CARDIAC REHABILITATION TREATMENT PLAN, DATE ATTENDING MD REFERRED PATIENT FOR TREATMENT

1,1


DATE ATTENDING MD SIGNED 0,1


DATE CARDIAC REHABILITATION PROFESSIONAL SIGNED

1,1

27542-0 DT 1,1



Page 21 May 2004


Value Data Type


27543-8 CARDIAC REHABILITATION TREATMENT PLAN, SIGNATURE OF RESPONSIBLE ATTENDING MD ON FILE

0,1

27543-8 N No Y Yes

CE 1,1 HL70136

27544-6 CARDIAC REHABILITATION TREATMENT PLAN, SIGNATURE OF RESPONSIBLE CARDIAC REHABILITATION PROFESSIONAL ON FILE

1,1

27544-6 N No Y Yes

CE 1,1 HL70136

27545-3 CARDIAC REHABILITATION TREATMENT PLAN, MEDICATION ADMINISTERED (COMPOSITE) Repeat the components as needed to report all medications administered as past of the rehabilitation treatment plan within the dates of service of the associated claim or for the period defined by the modifier codes. For additional details, see CDAR1AIS0006R021 Additional Information Specification 0006: Medications Attachment.

0,n

27461-3 CARDIAC REHABILITATION TREATMENT PLAN, MEDICATION NAME + IDENTIFIER NDC number and text preferred or just text. If none administered leave the attachment component out. To affirmatively document that none were administered use the "No Information" data type.

CE 1,1 See note at left. NDC (preferred)

27462-1 CARDIAC REHABILITATION TREATMENT PLAN, MEDICATION DOSE Supplement verbal information in the <content> element when units are complex or determined as unit per time.

NM 1,1 iso+

27463-9

CARDIAC REHABILITATION TREATMENT PLAN, MEDICATION TIMING + QUANTITY

TQ 1,1

27468-8 CARDIAC REHABILITATION TREATMENT PLAN, MEDICATION ROUTE See Section 5 for the list of valid codes.

CE 1,1 HL70162

27546-1 CARDIAC REHABILITATION TREATMENT PLAN, PROGNOSIS FOR CARDIAC REHABILITATION

1,1


CE 1,1 HL79005

27547-9 CARDIAC REHABILITATION TREATMENT PLAN, ESTIMATED DATE OF COMPLETION

1,1


DATE OF LAST PLAN OF TREATMENT CERTIFICATION

0,1


PAST MEDICAL HISTORY+LEVEL OF FUNCTION (NARRATIVE)

1,1

27549-5 TX 1,1


Page 22 May 2004



Value Data Type


27445-6 CARDIAC REHABILITATION TREATMENT PLAN, INITIAL ASSESSMENT (NARRATIVE)

1,1

27445-6 TX 1,1 27446-4 CARDIAC REHABILITATION TREATMENT PLAN,

PLAN OF TREATMENT (NARRATIVE) 1,1

27446-4 TX 1,1 27447-2 CARDIAC REHABILITATION TREATMENT,

PROGRESS NOTE+ATTAINMENT OF GOALS (NARRATIVE)

1,1


REASON TO CONTINUE (NARRATIVE) 0,1


JUSTIFICATION (NARRATIVE) 0,1

27449-8 TX 1,1

3.3 Medical Social Services Rehabilitation Value Table

Table 3.3 Medical Social Services Rehabilitation Value Table LOINC code



/ Numeric Units 27750-9 MEDICAL SOCIAL SERVICES TREATMENT PLAN,

NEW/REVISED 1,1


CE 1,1 HL79002

27751-7 MEDICAL SOCIAL SERVICES TREATMENT PLAN, DATE ONSET OR EXACERBATION OF PRIMARY DIAGNOSIS

1,1

27751-7 DT 1,1 27752-5 MEDICAL SOCIAL SERVICES TREATMENT PLAN,

START DATE 1,1



27791-3 MEDICAL SOCIAL SERVICES TREATMENT PLAN, PRIMARY DIAGNOSIS (IDENTIFIER) ICD-9CM code.

CE 1,1 I9C

27754-1 MEDICAL SOCIAL SERVICES TREATMENT PLAN, DIAGNOSIS ADDRESSED BY PLAN

1,1

27754-1 MEDICAL SOCIAL SERVICES TREATMENT PLAN, DIAGNOSIS ADDRESSED BY PLAN (IDENTIFIER) ICD-9CM code.

CE 1,1 I9C



Page 23 May 2004


Value Data Type


27755-8 MEDICAL SOCIAL SERVICES TREATMENT PLAN, AUTHOR OF TREATMENT PLAN (COMPOSITE)

1,1

27756-6 MEDICAL SOCIAL SERVICES TREATMENT PLAN, AUTHOR NAME

PN 1,1

27787-1 MEDICAL SOCIAL SERVICES TREATMENT PLAN, AUTHOR IDENTIFIER Unique identifier for the professional who established the treatment plan. At some point use of the National Provider Identifier (NPI) will be mandated, until such time other identifiers such as UPIN or state license number are allowed. Note: The @ S attribute will indicate the authority assigning the identifier; for example, NPI, UPIN, or XX, where XX is the two-letter US Postal Service abbreviation for the state of the licensing authority.


27757-4 MEDICAL SOCIAL SERVICES TREATMENT PLAN, AUTHOR PROFESSION As described by the Health Care Provider Taxonomy.

CE 0,1 PTX

27759-0 MEDICAL SOCIAL SERVICES TREATMENT PLAN, VISIT FREQUENCY

1,1

27759-0 TQ 1,1 27761-6 MEDICAL SOCIAL SERVICES TREATMENT PLAN,

DATE RANGE (FROM/THROUGH) DESCRIBED BY PLAN (COMPOSITE)

1,1

27762-4 MEDICAL SOCIAL SERVICES TREATMENT PLAN, PLAN START DATE

DT 1,1

27763-2 MEDICAL SOCIAL SERVICES TREATMENT PLAN, PLAN END DATE

DT 1,1

27764-0 MEDICAL SOCIAL SERVICES TREATMENT PLAN, DATE RANGE (FROM/THROUGH) OF HOSPITALIZAT ION LEADING TO TREATMENT (COMPOSITE)

0,1

27789-7 MEDICAL SOCIAL SERVICES TREATMENT PLAN, START DATE OF HOSPITALIZATION LEADING TO TREATMENT

DT 1,1

27790-5 MEDICAL SOCIAL SERVICES TREATMENT PLAN, END DATE OF HOSPITALIZATION LEADING TO TREATMENT

DT 1,1

27765-7 MEDICAL SOCIAL SERVICES TREATMENT PLAN, CONTINUATION STATUS

1,1


CE 1,1 HL79003

27766-5 MEDICAL SOCIAL SERVICES TREATMENT PLAN, DATE ATTENDING MD REFERRED PATIENT FOR TREATMENT

0,1




DATE MEDICAL SOCIAL SERVICES PROFESSIONAL SIGNED

1,1

27768-1 DT 1,1


Page 24 May 2004



Value Data Type


27770-7 MEDICAL SOCIAL SERVICES TREATMENT PLAN, SIGNATURE OF RESPONSIBLE MEDICAL SOCIAL SERVICES PROFESSIONAL ON FILE

1,1

27770-7 N No Y Yes

CE 1,1 HL70136

27769-9 MEDICAL SOCIAL SERVICES TREATMENT PLAN, SIGNATURE OF RESPONSIBLE ATTENDING MD ON FILE

0,1

27769-9 N No Y Yes

CE 1,1 HL70136

27771-5 MEDICAL SOCIAL SERVICES TREATMENT PLAN, MEDICATION ADMINISTERED (COMPOSITE) Identify all medications that were administered as part of the treatment plan within the dates of service of the associated claim or for the period defined by the modifier codes.

0,n

27792-1 MEDICAL SOCIAL SERVICES TREATMENT PLAN, MEDICATION NAME + IDENTIFIER NDC number and text preferred or just text. If none administered leave the attachment component out. To affirmatively document that none were administered use the "No Information" data type.


27793-9 MEDICAL SOCIAL SERVICES TREATMENT PLAN, MEDICATION DOSE Supplement verbal information in the <content> element when units are complex or determined as unit per time.

NM 1,1 iso+

27794-7 MEDICAL SOCIAL SERVICES TREATMENT PLAN, MEDICATION TIMING + QUANTITY

TQ 1,1

27799-6 MEDICAL SOCIAL SERVICES TREATMENT PLAN, MEDICATION ROUTE See Section 5 for the list of valid codes.

CE 1,1 HL70162

27772-3 MEDICAL SOCIAL SERVICES TREATMENT PLAN, PROGNOSIS FOR MEDICAL SOCIAL SERVICES

1,1


CE 1,1 HL79005

27773-1 MEDICAL SOCIAL SERVICES TREATMENT PLAN, ESTIMATED DATE OF COMPLETION

1,1



0,1



1,1

27775-6 TX 1,1 27776-4 MEDICAL SOCIAL SERVICES TREATMENT PLAN,

INITIAL ASSESSMENT (NARRATIVE) 1,1

27776-4 TX 1,1



Page 25 May 2004


Value Data Type


27777-2 MEDICAL SOCIAL SERVICES TREATMENT PLAN, PLAN OF TREATMENT (NARRATIVE)

1,1



1,1





27780-6 TX 1,1

3.4 Occupational Therapy Rehabilitation Service Value Table

Table 3.4 Occupational Therapy Rehabilitation Service Value Table LOINC code



/ Numeric Units 27597-4 OCCUPATIONAL THERAPY TREATMENT PLAN,

NEW/REVISED 1,1


CE 1,1 HL79002

27598-2 OCCUPATIONAL THERAPY TREATMENT PLAN, DATE ONSET OR EXACERBATION OF PRIMARY DIAGNOSIS

1,1

27598-2 DT 1,1 27472-0 OCCUPATIONAL THERAPY TREATMENT PLAN,

START DATE 1,1



27635-2 OCCUPATIONAL THERAPY TREATMENT PLAN, PRIMARY DIAGNOSIS (IDENTIFIER) ICD-9CM code.

CE 1,1 I9C

27601-4 OCCUPATIONAL THERAPY TREATMENT PLAN, DIAGNOSIS ADDRESSED BY PLAN

1,1

27601-4 OCCUPATIONAL THERAPY TREATMENT PLAN, DIAGNOSIS ADDRESSED BY PLAN (IDENTIFIER) ICD-9CM code.

CE 1,1 I9C


Page 26 May 2004



Value Data Type


27602-2 OCCUPATIONAL THERAPY TREATMENT PLAN, AUTHOR OF TREATMENT PLAN (COMPOSITE)

1,1

27603-0 OCCUPATIONAL THERAPY TREATMENT PLAN, AUTHOR NAME

PN 1,1

27634-5 OCCUPATIONAL THERAPY TREATMENT PLAN, AUTHOR IDENTIFIER Unique identifier for the professional who established the treatment plan. At some point use of the National Provider Identifier (NPI) will be mandated, until such time other identifiers such as UPIN or state license number are allowed. Note: The @ S attribute will indicate the authority assigning the identifier; for example, NPI, UPIN, or XX, where XX is the two-letter US Postal Service abbreviation for the state of the licensing authority.


27604-8 OCCUPATIONAL THERAPY TREATMENT PLAN, AUTHOR PROFESSION As described by the Health Care Provider Taxonomy.

CE 0,1 PTX

27606-3 OCCUPATIONAL THERAPY TREATMENT PLAN, VISIT FREQUENCY

1,1

27606-3 TQ 1,1 27608-9 OCCUPATIONAL THERAPY TREATMENT PLAN,


1,1

27609-7 OCCUPATIONAL THERAPY TREATMENT PLAN, PLAN START DATE

DT 1,1

27610-5 OCCUPATIONAL THERAPY TREATMENT PLAN, PLAN END DATE

DT 1,1

27611-3 OCCUPATIONAL THERAPY TREATMENT PLAN, DATE RANGE (FROM/THROUGH) OF HOSPITALIZATION LEADING TO TREATMENT (COMPOSITE)

0,1

27636-0 OCCUPATIONAL THERAPY TREATMENT PLAN, START DATE OF HOSPITALIZATION LEADING TO TREATMENT

DT 1,1

27637-8 OCCUPATIONAL THERAPY TREATMENT PLAN, END DATE OF HOSPITALIZATION LEADING TO TREATMENT

DT 1,1

27612-1 OCCUPATIONAL THERAPY TREATMENT PLAN, CONTINUATION STATUS

1,1

27612-1

C continue D discontinue

CE 1,1 HL79003

27613-9 OCCUPATIONAL THERAPY TREATMENT PLAN, DATE ATTENDING MD REFERRED PATIENT FOR TREATMENT

0,1




DATE OCCUPATIONAL THERAPY PROFESSIONAL SIGNED

1,1

27615-4 DT 1,1



Page 27 May 2004


Value Data Type


27616-2 OCCUPATIONAL THERAPY TREATMENT PLAN, SIGNATURE OF RESPONSIBLE ATTENDING MD ON FILE

0,1

27616-2 N No Y Yes

CE 1,1 HL70136

27617-0 OCCUPATIONAL THERAPY TREATMENT PLAN, SIGNATURE OF RESPONSIBLE OCCUPATIONAL THERAPY PROFESSIONAL ON FILE

1,1

27617-0 N No Y Yes

CE 1,1 HL70136

27618-8 OCCUPATIONAL THERAPY TREATMENT PLAN, MEDICATION ADMINISTERED (COMPOSITE) Identify all medications that were administered as part of the treatment plan within the dates of service of the associated claim or for the period defined by the modifier codes.

0,n

27639-4 OCCUPATIONAL THERAPY TREATMENT PLAN, MEDICATION NAME + IDENTIFIER NDC number and text preferred or just text, e.g.: 0008-0581-02. If none administered leave the attachment component out. To affirmatively document that none were administered use the "No Information" data type.


27640-2 OCCUPATIONAL THERAPY TREATMENT PLAN, MEDICATION DOSE Supplement verbal information in the <content> element when units are complex or determined as unit per time.

NM 1,1 iso+

27641-0 OCCUPATIONAL THERAPY TREATMENT PLAN, MEDICATION TIMING + QUANTITY

TQ 1,1

27646-9 OCCUPATIONAL THERAPY TREATMENT PLAN, MEDICATION ROUTE See Section 5 for the list of valid codes.

CE 1,1 HL70162

27619-6 OCCUPATIONAL THERAPY TREATMENT PLAN, PROGNOSIS FOR PHYSICAL THERAPY

1,1


CE 1,1 HL79005

27620-4 OCCUPATIONAL THERAPY TREATMENT PLAN, ESTIMATED DATE OF COMPLETION

1,1



0,1



1,1

27622-0 TX 1,1 27623-8 OCCUPATIONAL THERAPY TREATMENT PLAN,


27623-8 TX 1,1


Page 28 May 2004



Value Data Type


27624-6 OCCUPATIONAL THERAPY TREATMENT PLAN, PLAN OF TREATMENT (NARRATIVE)

1,1



1,1





27627-9 TX 1,1

3.5 Physical Therapy Rehabilitation Value Table

Table 3.5 Physical Therapy Rehabilitation Service Value Table LOINC code



/ Numeric Units 27660-0 PHYSICAL THERAPY TREATMENT PLAN,

NEW/REVISED 1,1


CE 1,1 HL79002

27661-8 PHYSICAL THERAPY TREATMENT PLAN, DATE ONSET OR EXACERBATION OF PRIMARY DIAGNOSIS

1,1

27661-8 DT 1,1 27662-6 PHYSICAL THERAPY TREATMENT PLAN, START

DATE 1,1

27662-6 DT 1,1 27698-0 PHYSICAL THERAPY TREATMENT PLAN, PRIMARY

DIAGNOSIS 1,1

27698-0 PHYSICAL THERAPY TREATMENT PLAN, PRIMARY DIAGNOSIS (IDENTIFIER) ICD-9CM code.

CE 1,1 I9C

27664-2 PHYSICAL THERAPY TREATMENT PLAN, DIAGNOSIS ADDRESSED BY PLAN

1,1

27664-2 PHYSICAL THERAPY TREATMENT PLAN, DIAGNOSIS ADDRESSED BY PLAN (IDENTIFIER) ICD-9CM code.

CE 1,1 I9C



Page 29 May 2004


Value Data Type


27665-9 PHYSICAL THERAPY TREATMENT PLAN, AUTHOR OF TREATMENT PLAN (COMPOSITE)

1,1

27666-7 PHYSICAL THERAPY TREATMENT PLAN, AUTHOR NAME

PN 1,1

27697-2 PHYSICAL THERAPY TREATMENT PLAN, AUTHOR IDENTIFIER Unique identifier for the professional who established the treatment plan. At some point use of the National Provider Identifier (NPI) will be mandated, until such time other identifiers such as UPIN or state license number are allowed. Note: The @ S attribute will indicate the authority assigning the identifier; for example, NPI, UPIN, or XX, where XX is the two-letter US Postal Service abbreviation for the state of the licensing authority.


27667-5 CARDIAC REHABILITATION TREATMENT PLAN, AUTHOR PROFESSION As described by the Health Care Provider Taxonomy.

CE 0,1 PTX

27669-1 PHYSICAL THERAPY TREATMENT PLAN, VISIT FREQUENCY

1,1

27669-1 TQ 1,1 27671-7 PHYSICAL THERAPY TREATMENT PLAN, DATE

RANGE (FROM/THROUGH) DESCRIBED BY PLAN (COMPOSITE)

1,1

27672-5 PHYSICAL THERAPY TREATMENT PLAN, PLAN START DATE

DT 1,1

27673-3 PHYSICAL THERAPY TREATMENT PLAN, PLAN END DATE

DT 1,1

27674-1 PHYSICAL THERAPY TREATMENT PLAN, DATE RANGE (FROM/THROUGH) OF HOSPITALIZATION LEADING TO TREATMENT (COMPOSITE)

0,1

27648-5 PHYSICAL THERAPY TREATMENT PLAN, START DATE OF HOSPITALIZATION LEADING TO TREATMENT

DT 1,1

27649-3 PHYSICAL THERAPY TREATMENT PLAN, END DATE OF HOSPITALIZATION LEADING TO TREATMENT

DT 1,1

27675-8 PHYSICAL THERAPY TREATMENT PLAN, CONTINUATION STATUS

1,1


CE 1,1 HL79003

27676-6 PHYSICAL THERAPY TREATMENT PLAN, DATE ATTENDING MD REFERRED PATIENT FOR TREATMENT

0,1

27676-6 DT 1,1 27677-4 PHYSICAL THERAPY TREATMENT PLAN, DATE

ATTENDING MD SIGNED 0,1

27677-4 DT 1,1 27678-2 PHYSICAL THERAPY TREATMENT PLAN, DATE

REHAB PROFESSIONAL SIGNED 1,1

27542-0 DT 1,1 27679-0 PHYSICAL THERAPY TREATMENT PLAN,

SIGNATURE OF RESPONSIBLE ATTENDING MD ON FILE

0,1

27679-0 N No Y Yes

CE 1,1 HL70136


Page 30 May 2004



Value Data Type


27680-8 PHYSICAL THERAPY TREATMENT PLAN, SIGNATURE OF PHYSICAL THERAPY PROFESSIONAL ON FILE

1,1

27680-8 N No Y Yes

CE 1,1 HL70136

27681-6 PHYSICAL THERAPY TREATMENT PLAN, MEDICATION ADMINISTERED (COMPOSITE) Identify all medications that were administered as part of the treatment plan within the dates of service of the associated claim or for the period defined by the modifier codes.

0..n

27651-9 PHYSICAL THERAPY TREATMENT PLAN, MEDICATION NAME + IDENTIFIER NDC number and text preferred or just text. If none administered leave the attachment component out. To affirmatively document that none were administered use the "No Information" data type.


27652-7 PHYSICAL THERAPY TREATMENT PLAN, MEDICATION DOSE Supplement verbal information in the <content> element when units are complex or determined as unit per time.

NM 1,1 iso+

27653-5 PHYSICAL THERAPY TREATMENT PLAN, MEDICATION TIMING + QUANTITY

TQ 1,1

27658-4 PHYSICAL THERAPY TREATMENT PLAN, MEDICATION ROUTE See Section 5 for the list of valid codes.

CE 1,1 HL70162

27682-4 PHYSICAL THERAPY TREATMENT PLAN, PROGNOSIS FOR PHYSICAL THERAPY

1,1


CE 1,1 HL79005

27683-2 PHYSICAL THERAPY TREATMENT PLAN, ESTIMATED DATE OF COMPLETION

1,1

27683-2 DT 1,1 27684-0 PHYSICAL THERAPY TREATMENT PLAN, DATE OF

LAST PLAN OF TREATMENT CERTIFICATION 0,1

27548-7 DT 1,1 27685-7 PHYSICAL THERAPY TREATMENT PLAN, PAST

MEDICAL HISTORY+LEVEL OF FUNCTION (NARRATIVE)

1,1

27685-7 TX 1,1 27685-5 PHYSICAL THERAPY TREATMENT PLAN, INITIAL

ASSESSMENT (NARRATIVE) 1,1

27685-5 TX 1,1 27687-3 PHYSICAL THERAPY TREATMENT PLAN, PLAN OF

TREATMENT (NARRATIVE) 1,1

27687-3 TX 1,1 27688-1 PHYSICAL THERAPY TREATMENT PLAN,


1,1

27688-1 TX 1,1



Page 31 May 2004


Value Data Type


27689-9 PHYSICAL THERAPY TREATMENT PLAN, REASON TO CONTINUE (NARRATIVE)

0,1

27689-9 TX 1,1 27690-7 PHYSICAL THERAPY TREATMENT PLAN,


27690-7 TX 1,1

3.6 Psychiatric Rehabilitation Service Value Table

Table 3.6 Psychiatric Rehabilitation Service Value Table LOINC code



/ Numeric Units 18626-2 PSYCHIATRIC REHABILITATION TREATMENT

PLAN, NEW/REVISED 1,1


CE 1,1 HL79002

18627-0 PSYCHIATRIC REHABILITATION TREATMENT PLAN, DATE ONSET OR EXAC ERBATION OF PRIMARY DIAGNOSIS

1,1

18627-0 DT 1,1 18628-8 PSYCHIATRIC REHABILITATION TREATMENT

PLAN, START DATE 1,1


PLAN, PRIMARY DIAGNOSIS 1,1

19007-4 PSYCHIATRIC REHABILITATION TREATMENT PLAN, PRIMARY DIAGNOSIS (IDENTIFIER) ICD-9CM code.

CE 1,1 I9C

18631-2 PSYCHIATRIC REHABILITATION TREATMENT PLAN, DIAGNOSIS ADDRESSED BY PLAN

1,1

18631-2 PSYCHIATRIC REHABILITATION TREATMENT PLAN, DIAGNOSIS ADDRESSED BY PLAN (IDENTIFIER) ICD-9CM code.

CE 1,1 I9C

18632-0 PSYCHIATRIC REHABILITATION TREATMENT PLAN, AUTHOR OF TREATMENT PLAN (COMPOSITE)

1,1

18633-8 PSYCHIATRIC REHABILITATION TREATMENT PLAN, AUTHOR NAME

PN 1,1

18730-2 PSYCHIATRIC REHABILITATION TREATMENT PLAN, AUTHOR IDENTIFIER Unique identifier for the professional who established the treatment plan. At some point use of the National Provider Identifier (NPI) will be mandated, until such time other identifiers such as UPIN or state license number are allowed. Note: The @ S attribute will indicate the authority assigning the identifier; for example, NPI, UPIN, or XX, where XX is the two-letter US Postal Service abbreviation for the state of the licensing authority.


18634-6 PSYCHIATRIC REHABILITATION TREATMENT PLAN, AUTHOR PROFESSION As described by the Health Care Provider Taxonomy.

CE 0,1 PTX

18637-9 PSYCHIATRIC REHABILITATION TREATMENT PLAN, VISIT FREQUENCY

1,1

18637-9 TQ 1,1


Page 32 May 2004



Value Data Type


18639-5 PSYCHIATRIC REHABILITATION TREATMENT PLAN, DATE RANGE (FROM/THROUGH) DESCRIBED BY PLAN (COMPOSITE)

1,1

18640-3 PSYCHIATRIC REHABILITATION TREATMENT PLAN, PLAN START DATE

DT 1,1

18641-1 PSYCHIATRIC REHABILITATION TREATMENT PLAN, PLAN END DATE

DT 1,1

18642-9 PSYCHIATRIC REHABILITATION TREATMENT PLAN, DATE RANGE (FROM/THROUGH) OF HOSPITALIZATION LEADING TO TREATMENT (COMPOSITE)

0,1

18643-7 PSYCHIATRIC REHABILITATION TREATMENT PLAN, START DATE OF HOSPITALIZATION LEADING TO TREATMENT

DT 1,1

18644-5 PSYCHIATRIC REHABILITATION TREATMENT PLAN, END DATE HOSPITALIZATION LEADING TO TREATMENT

DT 1,1

18645-2 PSYCHIATRIC REHABILITATION TREATMENT PLAN, CONTINUATION STATUS

1,1


CE 1,1 HL79003

18646-0 PSYCHIATRIC REHABILITATION TREATMENT PLAN, DATE ATTENDING MD REFERRED PATIENT FOR TREATMENT

0,1


PLAN, DATE ATTENDING MD SIGNED 0,1


PLAN, DATE REHAB PROFESSIONAL SIGNED 1,1


PLAN, SIGNATURE OF RESPONSIBLE ATTENDING MD ON FILE

0,1

18649-4 N No Y Yes

CE 1,1 HL70136

18650-2 PSYCHIATRIC REHABILITATION TREATMENT PLAN, SIGNATURE OF RESPONSIBLE REHAB PROFESSIONAL ON FILE

1,1

18650-2 N No Y Yes

CE 1,1 HL70136



Page 33 May 2004


Value Data Type


18651-0 PSYCHIATRIC REHABILITATION TREATMENT PLAN, MEDICATION ADMINISTERED (COMPOSITE) Identify all medications that were administered as part of the treatment plan within the dates of service of the associated claim or for the period defined by the modifier codes.

0,n

18816-9 PSYCHIATRIC REHABILITATION TREATMENT PLAN, MEDICATION NAME + IDENTIFIER NDC number and text preferred or just text. If none administered leave the attachment component out. To affirmatively document that none were administered use the "No Information" data type.


18817-7 PSYCHIATRIC REHABILITATION TREATMENT PLAN, MEDICATION DOSE Supplement verbal information in the <content> element when units are complex or determined as unit per time.

NM 1,1 iso+

18818-5 PSYCHIATRIC REHABILITATION TREATMENT PLAN, MEDICATION TIMING + QUANTITY

TQ 1,1

18819-3 PSYCHIATRIC REHABILITATION TREATMENT PLAN, MEDICATION ROUTE

CE 1,1 HL70162

18652-8 PSYCHIATRIC REHABILITATION TREATMENT PLAN, PROGNOSIS FOR REHABILITATION

1,1


CE 1,1 HL79005

18653-6 PSYCHIATRIC REHABILITATION TREATMENT PLAN, ESTIMATED DATE OF COMPLETION

1,1


PLAN, DATE OF LAST PLAN OF TREATMENT CERTIFICATION

0,1


PLAN, PAST MEDICAL HISTORY+LEVEL OF FUNCTION (NARRATIVE)

1,1

18655-1 TX 1,1 18656-9 PSYCHIATRIC REHABILITATION TREATMENT

PLAN, IN ITIAL ASSESSMENT (NARRATIVE) 1,1


PLAN, PLAN OF TREATMENT (NARRATIVE) 1,1


PLAN, PROGRESS NOTE+ATTAINMENT OF GOALS (NARRATIVE)

1,1


PLAN, REASON TO CONTINUE (NARRATIVE) 1,1


PLAN, JUSTIFICATION (NARRATIVE) 0,1


PLAN, PSYCHIATRIC SYMPTOMS (NARRATIVE) 0,1

18661-9 TX 1,1


Page 34 May 2004


3.7 Respiratory Therapy Rehabilitation Service Value Table

Table 3.7 Respiratory Therapy Rehabilitation Service Value Table LOINC code



/ Numeric Units 27699-8 RESPIRATORY THERAPY TREATMENT PLAN,

NEW/REVISED 1,1


CE 1,1 HL79002

27700-4 RESPIRATORY THERAPY TREATMENT PLAN, DATE ONSET OR EXACERBATION OF PRIMARY DIAGNOSIS

1,1

27700-4 DT 1,1 27701-2 RESPIRATORY THERAPY TREATMENT PLAN,

START DATE 1,1



27740-0 RESPIRATORY THERAPY TREATMENT PLAN, PRIMARY DIAGNOSIS (IDENTIFIER) ICD-9CM code.

CE 1,1 I9C

27703-8 RESPIRATORY THERAPY TREATMENT PLAN, DIAGNOSIS ADDRESSED BY PLAN

1,1

27703-8 RESPIRATORY THERAPY TREATMENT PLAN, DIAGNOSIS ADDRESSED BY PLAN (IDENTIFIER) ICD-9CM code.

CE 1,1 I9C

27704-6 RESPIRATORY THERAPY TREATMENT PLAN, AUTHOR OF TREATMENT PLAN (COMPOSITE)

1,1

27705-3 RESPIRATORY THERAPY TREATMENT PLAN, AUTHOR NAME

PN 1,1

27736-8 RESPIRATORY THERAPY TREATMENT PLAN, AUTHOR IDENTIFIER Unique identifier for the professional who established the treatment plan. At some point use of the National Provider Identifier (NPI) will be mandated, until such time other identifiers such as UPIN or state license number are allowed. Note: The @ S attribute will indicate the authority assigning the identifier; for example, NPI, UPIN, or XX, where XX is the two-letter US Postal Service abbreviation for the state of the licensing authority.


27706-1 RESPIRATORY THERAPY TREATMENT PLAN, AUTHOR PROFESSION As described by the Health Care Provider Taxonomy.

CE 0,1 PTX

27708-7 RESPIRATORY THERAPY TREATMENT PLAN, VISIT FREQUENCY

1,1

27708-7 TQ 1,1 27710-3 RESPIRATORY THERAPY TREATMENT PLAN,


1,1

27711-1 RESPIRATORY THERAPY TREATMENT PLAN, PLAN START DATE

DT 1,1

27712-9 RESPIRATORY THERAPY TREATMENT PLAN, PLAN END DATE

DT 1,1



Page 35 May 2004


Value Data Type


27713-7 RESPIRATORY THERAPY TREATMENT PLAN, DATE RANGE (FROM/THROUGH) OF HOSPITALIZATION LEADING TO TREATMENT (COMPOSITE)

0,1

27739-2 RESPIRATORY THERAPY TREATMENT PLAN, START DATE OF HOSPITALIZATION LEADING TO TREATMENT

DT 1,1

27738-4 RESPIRATORY THERAPY TREATMENT PLAN, END DATE OF HOSPITALIZATION LEADING TO TREATMENT

DT 1,1

27714-5 RESPIRATORY THERAPY TREATMENT PLAN, CONTINUATION STATUS

1,1

27714-5


CE 1,1 HL79003

27715-2 RESPIRATORY THERAPY TREATMENT PLAN, DATE ATTENDING MD REFERRED PATIENT FOR TREATMENT

0,1




DATE RESPIRATORY THERAPY PROFESSIONAL SIGNED

1,1


SIGNATURE OF RESPONSIBLE ATTENDING MD ON FILE

0,1

27718-6 N No Y Yes

CE 1,1 HL70136

27719-4 RESPIRATORY THERAPY TREATMENT PLAN, SIGNATURE OF RESPONSIBLE RESPIRATORY THERAPY PROFESSIONAL ON FILE

1,1

27719-4 N No Y Yes

CE 1,1 HL70136


Page 36 May 2004



Value Data Type


27720-2 RESPIRATORY THERAPY TREATMENT PLAN, MEDICATION ADMINISTERED (COMPOSITE) Identify all medications that were administe red as part of the treatment plan within the dates of service of the associated claim or for the period defined by the modifier codes.

0,n

27741-8 RESPIRATORY THERAPY TREATMENT PLAN, MEDICATION NAME + IDENTIFIER NDC number and text preferred or just text. If none administered leave the attachment component out. To affirmatively document that none were administered use the "No Information" data type.


27742-6 RESPIRATORY THERAPY TREATMENT PLAN, MEDICATION DOSE Supplement verbal information in the <content> element when units are complex or determined as unit per time.

NM 1,1 iso+

27743-4 RESPIRATORY THERAPY TREATMENT PLAN, MEDICATION TIMING + QUANTITY

TQ 1,1

27748-3 RESPIRATORY THERAPY TREATMENT PLAN, MEDICATION ROUTE See Section 5 for the list of valid codes.

CE 1,1 HL70162

27721-0 RESPIRATORY THERAPY TREATMENT PLAN, PROGNOSIS FOR RESPIRATORY THERAPY

1,1


CE 1,1 HL79005

27722-8 RESPIRATORY THERAPY TREATMENT PLAN, ESTIMATED DATE OF COMPLETION

1,1



0,1

27723-6 DT 1,1 27724-4 RESPIRATORY THERAPY TREATMENT PLAN, PAST


1,1

27724-4 TX 1,1 27725-1 RESPIRATORY THERAPY TREATMENT PLAN,


27725-1 TX 1,1 27726-9 RESPIRATORY THERAPY TREATMENT PLAN, PLAN

OF TREATMENT (NARRATIVE) 1,1



1,1





27729-3 TX 1,1



Page 37 May 2004

3.8 Skilled Nursing Rehabilitation Service Value Table

Table 3.8 Skilled Nursing Rehabilitation Service Value Table LOINC code



/ Numeric Units 27470-4 SKILLED NURSING TREATMENT PLAN,

NEW/REVISED 1,1

27470-4 See Section 5 for the list of valid codes.

CE 1,1 HL79002

27471-2 SKILLED NURSING TREATMENT PLAN, DATE ONSET OR EXACERBATION OF PRIMARY DIAGNOSIS

1,1

27471-2 DT 1,1 27472-0 SKILLED NURSING TREATMENT PLAN, START

DATE 1,1

27472-0 DT 1,1 27587-5 SKILLED NURSING TREATMENT PLAN, PRIMARY

DIAGNOSIS 1,1

27587-5 SKILLED NURSING TREATMENT PLAN, PRIMARY DIAGNOSIS (IDENTIFIER) ICD-9CM code.

CE 1,1 I9C

27550-3 SKILLED NURSING TREATMENT PLAN, DIAGNOSIS ADDRESSED BY PLAN

1,1

27550-3 SKILLED NURSING TREATMENT PLAN, DIAGNOSIS ADDRESSED BY PLAN (IDENTIFIER) ICD-9CM code.

CE 1,1 I9C

27551-1 SKILLED NURSING TREATMENT PLAN, AUTHOR OF TREATMENT PLAN (COMPOSITE)

1,1

27552-9 SKILLED NURSING TREATMENT PLAN, AUTHOR NAME

PN 1,1

27583-4 SKILLED NURSING TREATMENT PLAN, AUTHOR IDENTIFIER Unique identifier for the professional who established the treatment plan. At some point use of the National Provider Identifier (NPI) will be mandated, until such time other identifiers such as UPIN or state license number are allowed. Note: The @ S attribute will indicate the authority assigning the identifier; for example, NPI, UPIN, or XX, where XX is the two-letter US Postal Service abbreviation for the state of the licensing authority.


27553-7 SKILLED NURSING TREATMENT PLAN, AUTHOR PROFESSION As described by the Health Care Provider Taxonomy.

CE 0,1 PTX

27555-2 SKILLED NURSING TREATMENT PLAN, VISIT FREQUENCY

1,1

27555-2 TQ 1,1 27557-8 SKILLED NURSING TREATMENT PLAN, DATE


1,1

27558-6 SKILLED NURSING TREATMENT PLAN, PLAN START DATE

DT 1,1

27559-4 SKILLED NURSING TREATMENT PLAN, PLAN END DATE

DT 1,1


Page 38 May 2004



Value Data Type


27560-2 SKILLED NURSING TREATMENT PLAN, DATE RANGE (FROM/THROUGH) OF HOSPITALIZATION LEADING TO TREATMENT (COMPOSITE)

0,1

27586-7 SKILLED NURSING TREATMENT PLAN, START DATE OF HOSPITALIZATION LEADING TO TREATMENT

DT 1,1

27585-9 SKILLED NURSING TREATMENT PLAN, END DATE OF HOSPITALIZATION LEADING TO TREATMENT

DT 1,1

27561-0 SKILLED NURSING TREATMENT PLAN, CONTINUATION STATUS

1,1


CE 1,1 HL79003

27562-8 SKILLED NURSING TREATMENT PLAN, DATE ATTENDING MD REFERRED PATIENT FOR TREATMENT

0,1

27562-8 DT 1,1 27563-6 SKILLED NURSING TREATMENT PLAN, DATE


27563-6 DT 1,1 27564-4 SKILLED NURSING TREATMENT PLAN, DATE

NURSING PROFESSIONAL SIGNED 1,1

27564-4 DT 1,1 27565-1 SKILLED NURSING TREATMENT PLAN, SIGNATURE

OF RESPONSIBLE ATTENDING MD ON FILE 0,1

27565-1 N No Y Yes

CE 1,1 HL70136

27566-9 SKILLED NURSING TREATMENT PLAN, SIGNATURE OF RESPONSIBLE NURSING PROFESSIONAL ON FILE

1,1

27566-9 N No Y Yes

CE 1,1 HL70136



Page 39 May 2004


Value Data Type


27567-7 SKILLED NURSING TREATMENT PLAN, MEDICATION ADMINISTERED (COMPOSITE) Identify all medications that were administered as part of the treatment plan within the dates of service of the associated claim or for the period defined by the modifier codes.

0,n

27588-3 SKILLED NURSING TREATMENT PLAN, MEDICATION NAME + IDENTIFIER NDC number and text preferred or just text. If none administered leave the attachment component out. To affirmatively document that none were administered use the "No Information" data type.


27589-1 SKILLED NURSING TREATMENT PLAN, MEDICATION DOSE Supplement verbal information in the <content> element when units are complex or determined as unit per time.

NM 1,1 iso+

27590-9 SKILLED NURSING TREATMENT PLAN, MEDICATION TIMING + QUANTITY

TQ 1,1

27595-8 SKILLED NURSING TREATMENT PLAN, MEDICATION ROUTE See Section 5 for the list of valid codes.

CE 1,1 HL70162

27568-5 SKILLED NURSING TREATMENT PLAN, PROGNOSIS FOR REHABILITATION

1,1


CE 1,1 HL79005

27569-3 SKILLED NURSING TREATMENT PLAN, ESTIMATED DATE OF COMPLETION

1,1

27569-3 DT 1,1 27570-1 SKILLED NURSING TREATMENT PLAN, DATE OF


27570-1 DT 1,1 27571-9 SKILLED NURSING TREATMENT PLAN, PAST

MEDICAL HISTORY + LEVEL OF FUNCTION (NARRATIVE)

1,1

27571-9 TX 1,1 27572-7 SKILLED NURSING TREATMENT PLAN, INITIAL


27572-7 TX 1,1 27573-5 SKILLED NURSING TREATMENT PLAN, PLAN OF


27573-5 TX 1,1 27574-3 SKILLED NURSING TREATMENT PLAN, PROGRESS

NOTE+ATTAINMENT OF GOALS (NARRATIVE) 1,1

27574-3 TX 1,1 27575-0 SKILLED NURSING TREATMENT PLAN, REASON TO

CONTINUE (NARRATIVE) 0,1

27575-0 TX 1,1 27576-8 SKILLED NURSING TREATMENT PLAN,


27576-8 TX 1,1


Page 40 May 2004


3.9 Speech Therapy Rehabilitation Service Value Table

Table 3.9 Speech Therapy Rehabilitation Service Value Table LOINC code



/ Numeric Units 29162-5 SPEECH THERAPY TREATMENT PLAN,

NEW/REVISED 1,1


CE 1,1 HL79002

29163-3 SPEECH THERAPY TREATMENT PLAN, DATE ONSET OR EXACERBATION OF PRIMARY DIAGNOSIS

1,1

29163-3 DT 1,1 29164-1 SPEECH THERAPY TREATMENT PLAN, START DATE 1,1

29164-1 DT 1,1 29166-6 SPEECH THERAPY TREATMENT PLAN, PRIMARY

DIAGNOSIS 1,1

29166-6 SPEECH THERAPY TREATMENT PLAN, PRIMARY DIAGNOSIS (IDENTIFIER) ICD-9CM code.

CE 1,1 I9C

29167-4 SPEECH THERAPY TREATMENT PLAN, DIAGNOSIS ADDRESSED BY PLAN

1,1

29167-4 SPEECH THERAPY TREATMENT PLAN, DIAGNOSIS ADDRESSED BY PLAN (IDENTIFIER) ICD-9CM code.

CE 1,1 I9C

29168-2 SPEECH THERAPY TREATMENT PLAN, AUTHOR OF TREATMENT PLAN (COMPOSITE)

1,1

29189-8 SPEECH THERAPY TREATMENT PLAN, AUTHOR NAME PN 1,1 29188-0 SPEECH THERAPY TREATMENT PLAN, AUTHOR

IDENTIFIER Unique identifier for the professional who established the treatment plan. At some point use of the National Provider Identifier (NPI) will be mandated, until such time other identifiers such as UPIN or state license number are allowed. Note: The @ S attribute will indicate the authority assigning the identifier; for example, NPI, UPIN, or XX, where XX is the two-letter US Postal Service abbreviation for the state of the licensing authority.


29190-6 SPEECH THERAPY TREATMENT PLAN, AUTHOR PROFESSION As described by the Health Care Provider Taxonomy.

CE 0,1 PTX

29169-0 SPEECH THERAPY TREATMENT PLAN, VISIT FREQUENCY

1,1

29169-0 TQ 1,1 29170-8 SPEECH THERAPY TREATMENT PLAN, DATE


1,1

29201-1 SPEECH THERAPY TREATMENT PLAN, PLAN START DATE

DT 1,1

29191-4 SPEECH THERAPY TREATMENT PLAN, PLAN END DATE

DT 1,1



Page 41 May 2004


Value Data Type


29203-7 SPEECH THERAPY TREATMENT PLAN, DATE RANGE (FROM/THROUGH) OF HOSPITALIZATION LEADING TO TREATMENT (COMPOSITE)

0,1

29205-2 SPEECH THERAPY TREATMENT PLAN, START DATE OF HOSPITALIZATION LEADING TO TREATMENT

DT 1,1

29204-5 SPEECH THERAPY TREATMENT PLAN, END DATE OF HOSPITALIZATION LEADING TO TREATMENT

DT 1,1

29171-6 SPEECH THERAPY TREATMENT PLAN, CONTINUATION STATUS

1,1

29171-6


CE 1,1 HL79003

29172-4 SPEECH THERAPY TREATMENT PLAN, DATE ATTENDING MD REFERRED PATIENT FOR TREATMENT

0,1

29172-4 DT 1,1 29173-2 SPEECH THERAPY TREATMENT PLAN, DATE


29173-2 DT 1,1 29175-7 SPEECH THERAPY TREATMENT PLAN, DATE

SPEECH THERAPY PROFESSIONAL SIGNED 1,1

29175-7 DT 1,1 29174-0 SPEECH THERAPY TREATMENT PLAN, SIGNATURE

OF RESPONSIBLE ATTENDING MD ON FILE 0,1

29174-0 N No Y Yes

CE 1,1 HL70136

29176-5 SPEECH THERAPY TREATMENT PLAN, SIGNATURE OF RESPONSIBLE SPEECH THERAPY PROFESSIONAL ON FILE

1,1

29176-5 N No Y Yes

CE 1,1 HL70136

29177-3 SPEECH THERAPY TREATMENT PLAN, MEDICATION ADMINISTERED (COMPOSITE) Identify all medications that were administered as part of the treatment plan within the dates of service of the associated claim or for the period defined by the modifier codes.

0,n

29196-3 SPEECH THERAPY TREATMENT PLAN, MEDICATION NAME + IDENTIFIER NDC number and text preferred or just text. If none administered leave the attachment component out. To affirmatively document that none were administered use the "No Information" data type.


29199-7 SPEECH THERAPY TREATMENT PLAN, MEDICATION DOSE Supplement verbal information in the <content> element when units are complex or determined as unit per time.

NM 1,1 iso+

29198-9 SPEECH THERAPY TREATMENT PLAN, MEDICATION TIMING + QUANTITY

TQ 1,1

29197-1 SPEECH THERAPY TREATMENT PLAN, MEDICATION ROUTE See Section 5 for the list of valid codes.

CE 1,1 HL70162


Page 42 May 2004



Value Data Type


29178-1 SPEECH THERAPY TREATMENT PLAN, PROGNOSIS FOR THERAPY

1,1


CE 1,1 HL79005

29179-9 SPEECH THERAPY TREATMENT PLAN, ESTIMATED DATE OF COMPLETION

1,1

29179-9 DT 1,1 29180-7 SPEECH THERAPY TREATMENT PLAN, DATE OF


29180-7 DT 1,1 29181-5 SPEECH THERAPY TREATMENT PLAN, PAST


1,1

29181-5 TX 1,1 29182-3 SPEECH THERAPY TREATMENT PLAN, INITIAL


29182-3 TX 1,1 29183-1 SPEECH THERAPY TREATMENT PLAN, PLAN OF


29183-1 TX 1,1 29184-9 SPEECH THERAPY TREATMENT PLAN, PROGRESS

NOTE+ATTAINMENT OF GOALS (NARRATIVE) 1,1

29184-9 TX 1,1 29185-6 SPEECH THERAPY TREATMENT PLAN, REASON TO

CONTINUE (NARRATIVE) 0,1

29185-6 TX 1,1 29186-4 SPEECH THERAPY TREATMENT PLAN,


29186-4 TX 1,1



Page 43 May 2004

4 Coding Examples

4.1 Scenario The following message encodes a Psychiatric Rehabilitation plan for patient Jon J. Jay with medical record number 184569.

The claim associated with this CDA document is identified by the value XA728302 in data element TRN02-Attachment Control Number of Loop 2000A-Payer/Provider Control Number.

Figure 4.1 Psychiatric Rehabilitation Plan Data

PRINCIPAL DIAGNOSIS (IDENTIFIER) 296.4 (TEXT) BIPOLAR AFFECTIVE D/O OTHER DIAGNOSIS CODES None START OF CARE/ADMISSION DATE 06122003 STATEMENT FROM 07172003 through 07312003 PHYSICIAN JOHN E. SMITH, MD NEW JERSEY IDENTIFIER 1298379 PROVIDER TAXONOMY CODE Psychiatrist (203BP0800Y) REFERRAL DATE 06122003 REHAB PROFESSIONAL JONAH J. JONES, MS NEW JERSEY IDENTIFIER 3582901 PROVIDER TAXONOMY CODE Psychologist (103T00000N) PRIOR HOSPITALIZATION DATES 03262003 through 03292003 DATE OF ONSET/ EXACERBATION OF PRIN DX 03262003 TOTAL VISITS FROM START OF CARE 1 TREATMENT DIAGNOSIS (IDENTIFIER) 296.4 (TEXT) BIPOLAR AFFECTIVE D/O PLAN OF TREATMENT DATE ESTABLISHED 06122003 DATE SIGNED 06222003 FOR PERIOD 06222003 through 09222003 FREQUENCY/DURATION 3 VISITS PER WEEK FOR 90 DAYS ESTIMATED COMPLETION DATE 09302003 DATE PLAN LAST CERTIFIED (not applicable) PROGNOSIS 2 MEDICAL HISTORY/PRIOR FUNCTIONAL LEVEL PATIENT HAS HAD MULTIPLE PSYCHIATRIC HOSPITALIZATIONS OVER MANY YEARS, MOST RECENTLY 2 INPATIENT ADMISSIONS TO GENERAL HOSPITAL FOR SUICIDAL IDEATION AND SEVERE ANXIETY. PATIENT HAS BEEN UN OR UNDEREMPLOYED SINCE SUICIDE DEATH OF HIS TWIN BROTHER. INITIAL ASSESSMENT PATIENT IS EXTREMELY ANXIOUS, AGITATED AND NEEDY, CANNOT HOLD EMPLOYMENT, HAS DIFFICULTY ATTENDING PROGRAM REGULARLY, AND CANNOT SIT IN GROUPS FOR 10 MINUTES AT A TIME. RETURNS TO HOSPITAL INPATIENT WARDS WHENEVER ANXIETY BECOMES OVERWHELMING, WHICH IS OFTEN. FUNCTIONAL GOALS GOAL 1: PATIENT IS WORKING TO COME UP WITH ALTERNATIVES TO INPATIENT HOSPITALIZATION WHEN HE FEELS ABANDONED OR ANXIOUS GOAL 2: PATIENT IS EXPECTED TO RETURN TO THE LEVEL OF EMPLOYMENT THAT IS COMMENSORATE WITH HIS COGNITIVE ABILITIES. PLAN OF TREATMENT


Page 44 May 2004


915/90853 GROUP THERAPY: SYMPTOM MANAGEMENT 3X WEEK WITH PSYCHOLOGIST LAB WORK 1X MONTH: TO MONITOR LITHIUM FOR THERAPEUTIC LEVEL. MEDICATION ADMIN.: LITHIUM LEVEL 600 MG PO QAM, 900 MG PO QHS THIOTHIXENE 5 MG PO TID BENZTROPINE 1 MG PO TID INDOMETHACIN 50 MG PO TID PROGRESS REPORT 915/90853 GROUP THERAPY: SYMPTOM MANAGEMENT ON 7/17,22,24,27,29,31 WITH PSYCHOLOGIST: PATIENT MADE ATTEMPTS TO COME AND PARTICIPATE IN SYMPTOM MANAGEMENT GROUP. PATIENT WAS URGED TO USE ANXIETY CONTROL TECHNIQUES HE HAD BEEN TAUGHT TO TOLERATE INCREASING LONGER STAGES IN GROUP. PATIENT RESPONDED BY BEING ABLE TO STAY AND PARTICIPATE IN GROUP 50% LONGER. LAB WORK DONE ON {DATE} 07/17/00 {TEST} LITHIUM LEVEL {RESULT} 90 {JUSTIFY} ROUTINE MONITORING OF THERAPEUTIC RESPONSE. CONTINUED TREATMENT PATIENT HAS ACTIVE ANXIETY SYMPTOMS AND SUICIDAL IDEATION AND REQUIRES THIS LEVEL OF CARE TO HELP PREVENT RELAPSE AND INPATIENT TREATMENT. JUSTIFICATION FOR ADMISSION PATIENT HAD SEVERAL RECENT PSYCHIATRIC HOSPITALIZATIONS FOR ANXIETY AND SUICIDAL IDEATION, AND REQUIRED THE SUPPORT AND STRUCTURE OF DAY HOSPITAL PROGRAM TO PREVENT RELAPSE AND REHOSPITALIZATION. SYMPTOMS/PRESENT BEHAVIOR PATIENT WAS AGITATED, ANXIOUS AND NEEDY, EXPRESSING FEARS OF ABANDONMENT AND PASSIVE SUICIDAL IDEATION. PATIENT REQUIRED FREQUENT REINFORCEMENT IN ORDER TO CONTINUE TO FUNCTION OUTSIDE OF AN INPATIENT PSYCHIATRIC WARD.

4.1.1 Coded Rehabilitation Plan, Human-Decision Variant The right column of the example below contains the single HL7 document in the human-decision variant that conveys this report in its entirety. The left column provides help in relating the example to the scenario and to the Value Table.

Example 4.1.1 Psychiatric Rehabilitation Plan, Human-Decision Variant

Header <levelone xmlns="urn:hl7-org:v3/cda" xmlns:v3dt="urn:hl7-org:v3/v3dt" xmlns:xsi="http://www.w3.org/2001/XMLSchema-instance" xsi:schemaLocation="urn:hl7-org:v3/cda levelone_1.0.attachments.xsd"> <clinical_document_header> <id EX="a123" RT="2.16.840.1.113883.3.933"/> <document_type_cd V="18594-2" DN="Psychiatric Rehabilitation Attachment"/> <origination_dttm V="2003-08-12"/> <provider> <provider.type_cd V="PRF"/> <person> <id EX="298379" RT="2.16.840.1.113883.3.933"/> <person_name> <nm> <v3dt:GIV V="John"/> <v3dt:MID V="E"/> <v3dt:FAM V="Smith"/> <v3dt:SFX V="MD"/> </nm> <person_name.type_cd V="L" S="2.16.840.1.113883.5.200"/> </person_name> </person> </provider>



Page 45 May 2004

Patient Identification

<patient> <patient.type_cd V="PATSBJ"/> <person> <id EX="184569" RT="2.16.840.1.113883.3.933"/> <person_name> <nm> <v3dt:GIV V="Jon"/> <v3dt:FAM V="Jay"/> <v3dt:MID V="J"/> </nm> <person_name.type_cd V="L" S="2.16.840.1.113883.5.200"/> </person_name> </person> </patient>

Attachment Control Number

<local_header descriptor="Att_ACN"> <local_attr name="attachment_control_number" value="XA728302"/> </local_header> </clinical_document_header>

Status: original <body> <section> <caption>NEW/REVISED</caption> <paragraph> <content>New Plan</content> </paragraph> </section>

Primary Diagnosis Date: 3/26/03

<section> <caption>DATE ONSET OR EXACERBATION OF PRIMARY DIAGNOSIS </caption> <paragraph> <content>26 March 2003</content> </paragraph> </section>

Start date of rehab plan: 6/22/03

<section> <caption>START DATE</caption> <paragraph> <content>22 June 2003</content> </paragraph> </section>

Primary Diagnosis: 296.4

<section> <caption>PRIMARY DIAGNOSIS</caption> <paragraph> <content>bipolar affective disorder (296.4)</content> </paragraph> </section>

Plan Diagnosis: 296.4

<section> <caption>DIAGNOSIS ADDRESSED BY PLAN</caption> <paragraph> <content>bipolar affective disorder (296.4)</content> </paragraph> </section>

Professional who prescribed the plan: name, ID number, and professional designation

<section> <caption>AUTHOR OF TREATMENT PLAN </caption> <paragraph> <caption>AUTHOR NAME</caption> <content>JOHN E SMITH, MD</content> </paragraph> <paragraph> <caption>AUTHOR IDENTIFIER</caption> <content> 3582901 (NJ)</content> </paragraph> <paragraph> <caption>AUTHOR PROFESSION</caption> <content>103T00000N Psychologist</content> </paragraph> </section>

3 visits/wk for 90 days

<section> <caption>VISIT FREQUENCY </caption> <paragraph> <content>3 visits per week for 90 days</content> </paragraph>


Page 46 May 2004


</section>

Plan start and end dates 6/22/03 – 9/22/03

<section> <caption>DATE RANGE (FROM/THROUGH) DESCRIBED BY PLAN </caption> <paragraph> <caption>START DATE</caption> <content>22 June 2003</content> </paragraph> <paragraph> <caption>PLAN END DATE</caption> <content>22 Sep 2003</content> </paragraph> </section>

Prior hospitalization dates: 3/26/03 – 3/29/03

<section> <caption>DATE RANGE (FROM/THROUGH) OF HOSPITALIZATION LEADING TO TREATMENT </caption> <paragraph> <caption>START DATE</caption> <content>26 March 2003</content> </paragraph> <paragraph> <caption>END DATE</caption> <content>29 March 2003</content> </paragraph> </section>

Plan continuation status: continue

<section> <caption>CONTINUATION STATUS</caption> <paragraph> <content>Continue</content> </paragraph> </section>

Referral date: 6/12/03

<section> <caption>DATE ATTENDING MD REFERRED PATIENT FOR TREATMENT </caption> <paragraph> <content>12 June 2003</content> </paragraph> </section>

Date attending MD signed plan: 6/28/03

<section> <caption>DATE ATTENDING MD SIGNED</caption> <paragraph> <content>28 June 2003</content> </paragraph> </section>

Date signed by rehab professional: 6/28/03

<section> <caption>DATE REHAB PROFESSIONAL SIGNED</caption> <paragraph> <content>28 June 2003</content> </paragraph> </section>

Attending MD signature on file: yes

<section> <caption>SIGNATURE OF RESPONSIBLE ATTENDING MD ON FILE </caption> <paragraph> <content>Yes</content> </paragraph> </section>

Rehab professional signature on file: yes

<section> <caption>SIGNATURE OF RESPONSIBLE REHAB PROFESSIONAL ON FILE </caption> <paragraph> <content>Yes</content> </paragraph> </section>

Psych medications per plan. Lithium 600 mg by

<section> <caption>Medications Administered> </caption> <table cellpadding="15"> <tbody>



Page 47 May 2004

mouth each morning and 900 mg by mouth before sleeping. Thiothixene 5 mg by mouth three times a day. Benztropine 1 mg by mouth three times a day. Indomethacin 50 mg by mouth three times a day.

<tr><td>LITHIUM 600 mg QAM PO</td></tr> <tr><td>LITHIUM 900 mg QHS PO</td></tr> <tr><td>THIOTHIXENE 5 mg TID PO </td></tr> <tr><td>BENZTROPINE 5 mg TID PO </td></tr> <tr><td>INDOMETHACIN 50 mg TID PO</td></tr> </tbody> </table> </section>

Prognosis: guarded <section><caption>PROGNOSIS FOR REHABILITATION </caption> <paragraph> <content>Guarded</content> </paragraph> </section>

Estimated completion date: 09/30/03

<section> <caption>ESTIMATED DATE OF COMPLETION</caption> <paragraph> <content>30 Sept 2003 <local_markup descriptor="dt_DT" ignore="all"> 2003-09-30</local_markup> </content> </paragraph> </section>

Date last certification (no data sent)

Medical History and Functional Level

<section> <caption>PAST MEDICAL HISTORY + LEVEL OF FUNCTION </caption> <paragraph> <content>PATIENT HAS HAD MULTIPLE PSYCHIATRIC HOSPITALIZATIONS OVER MANY YEARS, MOST RECENTLY 2 INPATIENT ADMISSIONS TO GENERAL HOSPITAL FOR SUICIDAL IDEATION AND SEVERE ANXIETY. PA TIENT HAS BEEN UN OR UNDEREMPLOYED SINCE SUICIDE DEATH OF HIS TWIN BROTHER </content> </paragraph> </section>

Initial Assessment <section> <caption>INITIAL ASSESSMENT</caption> <paragraph> <content>PATIENT IS EXTREMELY ANXIOUS, AGITATED AND NEEDY, CANNOT HOLD EMPLOYMENT, HAS DIFFICULTY ATTENDING PROGRAM REGULARLY, AND CANNOT SIT IN GROUPS FOR 10 MINUTES AT A TIME. RETURNS TO HOSPITAL INPATIENT WARDS WHENEVER ANXIETY BECOMES OVERWHELMING, WHICH IS OFTEN.</content> </paragraph> </section>

Plan of Treatment <section> <caption>PLAN OF TREATMENT</caption> <list> <item><content>FUNCTIONAL GOALS.</content> <list> <item><content>GOAL 1: PATIENT IS WORKING TO COME UP WITH ALTERNATIVES TO INPATIENT HOSPITALIZATION WHEN HE FEELS ABANDONED OR ANXIOUS.</content></item> <item><content>GOAL 2: PATIENT IS EXPECTED TO RETURN TO THE LEVEL OF EMPLOYMENT THAT IS COMMENSORATE WITH HIS COGNITIVE ABILITIES..</content></item> </list> </item> <item><content>PLAN OF TREATMENT</content> <list> <item><content>915/90853 GROUP THERAPY: SYMPTOM MANAGEMENT 3X WEEK WITH PSYCHOLOGIST</content></item> <item><content>LABWORK 1X MONTH: TO MONITOR LITHIUM


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FOR THERAPEUTIC LEVEL.</content></item> </list> </item> </list> </section>

Progress Note <section> <caption>PROGRESS NOTE + ATTAINMENT OF GOALS </caption> <paragraph> <content>915/90853 GROUP THERAPY: SYMPTOM MANAGEMENT ON 7/17,22,24,27,29,31 WITH PSYCHOLOGIST: PATIENT MADE ATTEMPTS TO COME AND PARTICIPATE IN SYMPTOM MANAGEMENT GROUP. PATIENT WAS URGED TO USE ANXIETY CONTROL TECHNIQUES HE HAD BEEN TAUGHT TO TOLERATE INCREASING LONGER STAGES IN GROUP. PATIENT RESPONDED BY BEING ABLE TO STAY AND PARTICIPATE IN GROUP 50% LONGER</content> </paragraph> <paragraph> <content>DONE ON {DATE}07/17/98 {TEST}LITHIUM LEVEL {RESULT}90 {JUSTIF.}ROUTINE MONITORING OF THERAPEUTIC RESPONSE.</content> </paragraph> </section>

Reason to continue treatment plan

<section> <caption>REASON TO CONTINUE</caption> <paragraph> <content>PATIENT HAS ACTIVE ANXIETY SYMPTOMS AND SUICIDAL IDEATION AND REQUIRES THIS LEVEL OF CARE TO HELP PREVENT RELAPSE AND INPATIENT TREATMENT.</content> </paragraph> </section>

Justification for rehabilitation

<section> <caption>JUSTIFICATION</caption> <paragraph> <content>PATIENT HAD SEVERAL RECENT PSYCHIATRIC HOSPITALIZATIONS FOR ANXIETY AND SUICIDAL IDEATION, AND REQUIRED THE SUPPORT AND STRUCTURE OF DAY HOSPITAL PROGRAM TO PREVENT RELAPSE AND REHOSPITALIZATION.</content> </paragraph> </section>

Psychiatric symptoms

<section> <caption>PSYCHIATRIC SYMPTOMS</caption> <paragraph> <content>PATIENT WAS AGITATED, ANXIOUS AND NEEDY, EXPRESSING FEARS OF ABANDONMENT AND PASSIVE SUICIDAL IDEATION. PATIENT REQUIRED FREQUENT REINFORCEMENT IN ORDER TO CONTINUE TO FUNCTION OUTSIDE OF AN INPATIENT PSYCHIATRIC WARD.</content> </paragraph> </section> </body> </levelone>

Figure 1 shows a portion of the human-decision variant as rendered by a popular browser.



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Figure 1. Portion of Rendered Human-Decision Variant


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4.1.2 Coded Rehabilitation Plan, Computer-Decision Variant The right column of the example below contains the single HL7 Additional Information CDA document in the computer-decision variant that conveys this report in its entirety. The left column provides help in relating the example to the scenario and to the Value Table.

Example 4.1.2 Psychiatric Rehabilitation Plan, Computer-Decision Variant

Header <levelone xmlns="urn:hl7-org:v3/cda" xmlns:v3dt="urn:hl7-org:v3/v3dt" xmlns:xsi="http://www.w3.org/2001/XMLSchema-instance" xsi:schemaLocation="urn:hl7-org:v3/cda levelone_1.0.attachments.xsd"> <clinical_document_header> <id EX="a123" RT="2.16.840.1.113883.3.933"/> <document_type_cd V="18594-2" DN="Psychiatric Rehabilitation Attachment"/> <origination_dttm V="2003-08-12"/> <provider> <provider.type_cd V="PRF"/> <person> <id EX="298379" RT="2.16.840.1.113883.3.933"/> <person_name> <nm> <v3dt:GIV V="John"/> <v3dt:MID V="E"/> <v3dt:FAM V="Smith"/> <v3dt:SFX V="MD"/> </nm> <person_name.type_cd V="L" S="2.16.840.1.113883.5.200"/> </person_name> </person> </provider>

Patient Identification

<patient> <patient.type_cd V="PATSBJ"/> <person> <id EX="184569" RT="2.16.840.1.113883.3.933"/> <person_name> <nm> <v3dt:GIV V="Jon"/> <v3dt:FAM V="Jay"/> <v3dt:MID V="J"/> </nm> <person_name.type_cd V="L" S="2.16.840.1.113883.5.200"/> </person_name> </person> </patient>

Attachment Control Number

<local_header descriptor="Att_ACN"> <local_attr name="attachment_control_number" value="XA728302"/> </local_header> </clinical_document_header>

Status: original <body> <section> <caption><caption_cd V="18626-2" S="2.16.840.1.113883.6.1"/>NEW/REVISED</caption> <paragraph> <content>New Plan <coded_entry> <coded_entry.value V="700" S="2.16.840.1.113883.12.9002" SN="HL79002"/> </coded_entry> </content> </paragraph> </section>

Primary Diagnosis Date: 3/26/03

<section> <caption><caption_cd V="18627-0" S="2.16.840.1.113883.6.1"/> DATE ONSET OR EXACERBATION OF PRIMARY DIAGNOSIS </caption> <paragraph>



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<content>26 March 2003 <local_markup descriptor="dt_DT" ignore="all">2003-03-26</local_markup> </content> </paragraph> </section>

Start date of rehab plan: 6/22/03

<section> <caption><caption_cd V="18628-8" S="2.16.840.1.113883.6.1"/> START DATE</caption> <paragraph> <content>22 June 2003 <local_markup descriptor="dt_DT" ignore="all"> 2003-06-22</local_markup> </content> </paragraph> </section>

Primary Diagnosis: 296.4

<section> <caption><caption_cd V="19007-4" S="2.16.840.1.113883.6.1"/> PRIMARY DIAGNOSIS</caption> <paragraph> <content>bipolar affective disorder (296.4) <coded_entry> <coded_entry.value V="296.4" S="2.16.840.1.113883.6.2" SN="ICD-9-CM"/> </coded_entry> </content> </paragraph> </section>

Plan Diagnosis: 296.4

<section> <caption><caption_cd V="18631-2" S="2.16.840.1.113883.6.1"/> DIAGNOSIS ADDRESSED BY PLAN </caption> <paragraph> <content>bipolar affective disorder (296.4) <coded_entry> <coded_entry.value V="296.4" S="2.16.840.1.113883.6.2" SN="ICD-9-CM"/> </coded_entry> </content> </paragraph> </section>

Professional who prescribed the plan: name, ID number, and professional designation

<section> <caption><caption_cd V="18632-0" S="2.16.840.1.113883.6.1"/> AUTHOR OF TREATMENT PLAN </caption> <paragraph> <caption><caption_cd V="18633-8" S="2.16.840.1.113883.6.1"/> AUTHOR NAME </caption> <content>JOHN E SMITH, MD <local_markup descriptor="dt_PN"> <local_markup descriptor="dt_PN_GIV"> JOHN</local_markup> <local_markup descriptor="dt_PN_MID">E </local_markup> <local_markup descriptor="dt_PN_FAM"> SMITH</local_markup> <local_markup descriptor="dt_PN_SFX">MD </local_markup> </local_markup> </content> </paragraph> <paragraph> <caption><caption_cd V="18730-2" S="2.16.840.1.113883.6.1"/> AUTHOR IDENTIFIER </caption> <content> 3582901 (NJ) <local_markup descriptor="dt_CX"> <local_attr name="dt_CX_EX" value="3582901"/> <local_attr name="dt_CX_RT" value="2.16.840.1.113883.5.1"/>


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</local_markup> </content> </paragraph> <paragraph> <caption><caption_cd V="18634-6" S="2.16.840.1.113883.6.1"/> AUTHOR PROFESSION </caption> <content>103T00000N Psychologist <coded_entry> <coded_entry.value V="103T00000N " S=" 2.16.840.1.113883.6.101 " SN="USProvTxnmy "/> </coded_entry> </content> </paragraph> </section>

3 visits/wk for 90 days

<section> <caption><caption_cd V="18637-9" S="2.16.840.1.113883.6.1"/> VISIT FREQUENCY </caption> <paragraph> <content>3 visits per week for 90 days</content> </paragraph> </section>

Plan start and end dates 6/22/03 – 9/22/03

<section> <caption><caption_cd V="18639-5" S="2.16.840.1.113883.6.1"/> DATE RANGE (FRESCRIBED BY PLAN </caption> <paragraph> <caption><caption_cd V="18640-3" S="2.16.840.1.113883.6.1"/> START DATE</caption> <content>22 June 2003 <local_markup descriptor="dt_DT" ignore="all"> 2003-06-22</local_markup> </content> </paragraph> <paragraph> <caption><caption_cd V="18641-1" S="2.16.840.1.113883.6.1"/> PLAN END DATE</caption> <content>22 Sep 2003 <local_markup descriptor="dt_DT" ignore="all"> 2003-09-22</local_markup> </content> </paragraph> </section>

Prior hospitalization dates: 3/26/03 – 3/29/03

<section> <caption><caption_cd V="18642-9" S="2.16.840.1.113883.6.1"/> DATE RANGE (FROM/THROUGH) OF HOSPITALIZATION LEADING TO TREATMENT </caption> <paragraph> <caption><caption_cd V="18643-7" S="2.16.840.1.113883.6.1"/> START DATE OF HOSPITALIZATION LEADING TO TREATMENT </caption> <content>26 March 2003 <local_markup descriptor="dt_DT" ignore="all"> 2003-03-26</local_markup> </content> </paragraph> <paragraph> <caption><caption_cd V="18644-5" S="2.16.840.1.113883.6.1"/> END DATE OF HOSPITALIZATION LEADING TO TREATMENT </caption> <content>29 March 2003 <local_markup descriptor="dt_DT" ignore="all"> 2003-03-29</local_markup> </content> </paragraph> </section>

Plan continuation status: continue

<section> <caption><caption_cd V="18645-2" S="2.16.840.1.113883.6.1"/> CONTINUATION STATUS



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</caption> <paragraph> <content>Continue <coded_entry> <coded_entry.value V="C" S="2.16.840.1.113883.12.9003" SN="Rehab continue/discontinue"/> </coded_entry> </content> </paragraph> </section>

Referral date: 6/12/03

<section> <caption><caption_cd V="18646-0" S="2.16.840.1.113883.6.1"/> DATE ATTENDING MD REFERRED PATIENT FOR TREATMENT </caption> <paragraph> <content>12 June 2003 <local_markup descriptor="dt_DT" ignore="all">2003-06-12</local_markup> </content> </paragraph> </section>

Date attending MD signed plan: 6/28/03

<section> <caption><caption_cd V="18647-8" S="2.16.840.1.113883.6.1"/> DATE ATTENDING MD SIGNED </caption> <paragraph> <content>28 June 2003 <local_markup descriptor="dt_DT" ignore="all"> 2003-06-28</local_markup> </content> </paragraph> </section>

Date signed by rehab professional: 6/28/03

<section> <caption><caption_cd V="18648-6" S="2.16.840.1.113883.6.1"/> DATE REHAB PROFESSIONAL SIGNED </caption> <paragraph> <content>28 June 2003 <local_markup descriptor="dt_DT" ignore="all"> 2003-06-28</local_markup> </content> </paragraph> </section>

Attending MD signature on file: yes

<section> <caption><caption_cd V="18649-4" S="2.16.840.1.113883.6.1"/> SIGNATURE OF RESPONSIBLE ATTENDING MD ON FILE </caption> <paragraph> <content>Yes <coded_entry> <coded_entry.value V="Y" S="2.16.840.1.113883.12.136" SN="HL7 Yes/No"/> </coded_entry> </content> </paragraph> </section>

Rehab professional signature on file: yes

<section> <caption><caption_cd V="18650-2" S="2.16.840.1.113883.6.1"/> SIGNATURE OF RESPONSIBLE REHAB PROFESSIONAL ON FILE </caption> <paragraph> <content>Yes <coded_entry> <coded_entry.value V="Y" S="2.16.840.1.113883.12.136" SN="HL70136"/> </coded_entry> </content> </paragraph> </section>


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Psych medications per plan. Lithium 600 mg by mouth each morning and 900 mg by mouth before sleeping.

<section> <caption><caption_cd V="18651-0" S="2.16.840.1.113883.6.1"/> Medications Administered </caption> <table cellpadding="15"> <thead> <tr> <th><caption_cd V="18816-9" S="2.16.840.1.113883.6.1"/> Medication </th> <th><caption_cd V="18817-7" S="2.16.840.1.113883.6.1"/> Dose </th> <th><caption_cd V="18818-5" S="2.16.840.1.113883.6.1"/> Timing </th> <th><caption_cd V="18819-3" S="2.16.840.1.113883.6.1"/> Route </th> </tr> </thead> <tbody> <tr> <td>LITHIUM</td> <td align="right">600 mg <local_markup descriptor="dt_nm" ignore="all">600 <coded_entry> <coded_entry.value V="mg" S="2.16.840.1.113883.5.141"/> </coded_entry> </local_markup > </td> <td>QAM <local_markup descriptor="dt_TQ"> <local_markup descriptor="dt_TQ_IVL" ignore="all">QAM </local_markup> </local_markup> </td> <td>Oral <coded_entry> <coded_entry.value V="PO" S="2.16.840.1.113883.12.162" SN="HL7 Yes/No"/> </coded_entry> </td> </tr> <tr> <td>LITHIUM</td> <td align="right">900 mg <local_markup descriptor="dt_nm" ignore="all">900 <coded_entry> <coded_entry.value V="mg" S="2.16.840.1.113883.5.141"/> </coded_entry> </local_markup > </td> <td>at bedtime <local_markup descriptor="dt_TQ"> <local_markup descriptor="dt_TQ_IVL" ignore="all">QHS </local_markup> </local_markup> </td> <td>Oral <coded_entry> <coded_entry.value V="PO" S="2.16.840.1.113883.12.162" SN="Route of administration"/> </coded_entry> </td> </tr> <tr>



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Thiothixene 5 mg by mouth three times a day. Benztropine 1 mg by mouth three times a day. Indomethacin 50 mg by mouth three times a day.

<td>THIOTHIXENE</td> <td align="right">5 mg <local_markup descriptor="dt_nm" ignore="all">5 <coded_entry> <coded_entry.value V="mg" S="2.16.840.1.113883.5.141"/> </coded_entry> </local_markup > </td> <td>TID <local_markup descriptor="dt_TQ"> <local_markup descriptor="dt_TQ_IVL" ignore="all">TID </local_markup> </local_markup> </td> <td>Oral <coded_entry> <coded_entry.value V="PO" S="2.16.840.1.113883.12.162" SN="Route of administration"/> </coded_entry> </td> </tr> <tr> <td>BENZTROPINE</td> <td align="right">5 mg <local_markup descriptor="dt_nm" ignore="all">5 <coded_entry> <coded_entry.value V="mg" S="2.16.840.1.113883.5.141"/> </coded_entry> </local_markup > </td> <td>TID <local_markup descriptor="dt_TQ"> <local_markup descriptor="dt_TQ_IVL" ignore="all">TID </local_markup> </local_markup> </td> <td>Oral <coded_entry> <coded_entry.value V="PO" S="2.16.840.1.113883.12.162" SN="Route of administration"/> </coded_entry> </td> </tr> <tr> <td>INDOMETHACIN</td> <td align="right">50 mg <local_markup descriptor="dt_nm" ignore="all">50 <coded_entry> <coded_entry.value V="mg" S="2.16.840.1.113883.5.141"/> </coded_entry> </local_markup > </td> <td>TID <local_markup descriptor="dt_TQ"> <local_markup descriptor="dt_TQ_IVL" ignore="all">TID </local_markup> </local_markup> </td> <td>Oral <coded_entry> <coded_entry.value V="PO" S="2.16.840.1.113883.12.162 </coded_entry> </td> </tr> </tbody>


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</table> </section>

Prognosis: guarded <section> <caption> <caption_cd V="18652-8" S="2.16.840.1.113883.6.1"/> PROGNOSIS FOR REHABILITATION </caption> <paragraph> <content>Guarded <coded_entry> <coded_entry.value V="2" S="2.16.840.1.113883.12.9005" SN="Rehabilitation Plan Prognosis"/> </coded_entry> </content> </paragraph> </section>

Estimated completion date: 09/30/03

<section> <caption><caption_cd V="18653-6" S="2.16.840.1.113883.6.1"/> ESTIMATED DATE OF COMPLETION </caption> <paragraph> <content>30 Sept 2003 <local_markup descriptor="dt_DT" ignore="all"> 2003-09-30</local_markup> </content> </paragraph> </section>

Date last certification (no data sent)

Medical History and Functional Level

<section> <caption><caption_cd V="18655-1" S="2.16.840.1.113883.6.1"/> PAST MEDICAL HISTORY + LEVEL OF FUNCTION </caption> <paragraph> <content>PATIENT HAS HAD MULTIPLE PSYCHIATRIC HOSPITALIZATIONS OVER MANY YEARS, MOST RECENTLY 2 INPATIENT ADMISSIONS TO GENERAL HOSPITAL FOR SUICIDAL IDEATION AND SEVERE ANXIETY. PATIENT HAS BEEN UN OR UNDEREMPLOYED SINCE SUICIDE DEATH OF HIS TWIN BROTHER </content> </paragraph> </section>

Initial Assessment <section> <caption><caption_cd V="18656-9" S="2.16.840.1.113883.6.1"/> INITIAL ASSESSMENT </caption> <paragraph> <content>PATIENT IS EXTREMELY ANXIOUS, AGITATED AND NEEDY, CANNOT HOLD EMPLOYMENT, HAS DIFFICULTY ATTENDING PROGRAM REGULARLY, AND CANNOT SIT IN GROUPS FOR 10 MINUTES AT A TIME. RETURNS TO HOSPITAL INPATIENT WARDS WHENEVER ANXIETY BECOMES OVERWHELMING, WHICH IS OFTEN.</content> </paragraph> </section>

Plan of Treatment <section> <caption><caption_cd V="18657-7" S="2.16.840.1.113883.6.1"/> PLAN OF TREATMENT</caption> <list> <item><content>FUNCTIONAL GOALS.</content> <list> <item><content>GOAL 1: PATIENT IS WORKING TO COME UP WITH ALTERNATIVES TO INPATIENT HOSPITALIZATION WHEN HE FEELS ABANDONED OR ANXIOUS.</content></item> <item><content>GOAL 2: PATIENT IS EXPECTED TO RETURN TO THE LEVEL OF EMPLOYMENT THAT IS COMMENSORATE WITH HIS COGNITIVE ABILITIES..</content></item> </list> </item> <item><content>PLAN OF TREATMENT</content> <list>



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<item><content>915/90853 GROUP THERAPY: SYMPTOM MANAGEMENT 3X WEEK WITH PSYCHOLOGIST</content></item> <item><content>LABWORK 1X MONTH: TO MONITOR LITHIUM FOR THERAPEUTIC LEVEL.</content></item> </list> </item> </list> </section>

Progress Note <section> <caption><caption_cd V="18658-5" S="2.16.840.1.113883.6.1"/> PROGRESS NOTE + ATTAINMENT OF GOALS </caption> <paragraph> <content>915/90853 GROUP THERAPY: SYMPTOM MANAGEMENT ON 7/17,22,24,27,29,31 WITH PSYCHOLOGIST: PATIENT MADE ATTEMPTS TO COME AND PARTICIPATE IN SYMPTOM MANAGEMENT GROUP. PATIENT WAS URGED TO USE ANXIETY CONTROL TECHNIQUES HE HAD BEEN TAUGHT TO TOLERATE INCREASING LONGER STAGES IN GROUP. PATIENT RESPONDED BY BEING ABLE TO STAY AND PARTICIPATE IN GROUP 50% LONGER</content> </paragraph> <paragraph> <content>DONE ON {DATE}07/17/98 {TEST}LITHIUM LEVEL {RESULT}90 {JUSTIF.}ROUTINE MONITORING OF THERAPEUTIC RESPONSE.</content> </paragraph> </section>

Reason to continue treatment plan

<section> <caption><caption_cd V="18659-3" S="2.16.840.1.113883.6.1"/> REASON TO CONTINUE </caption> <paragraph> <content>PATIENT HAS ACTIVE ANXIETY SYMPTOMS AND SUICIDAL IDEATION AND REQUIRES THIS LEVEL OF CARE TO HELP PREVENT RELAPSE AND INPATIENT TREATMENT.</content> </paragraph> </section>

Justification for rehabilitation

<section> <caption><caption_cd V="18660-1" S="2.16.840.1.113883.6.1"/> JUSTIFICATION</caption> <paragraph> <content>PATIENT HAD SEVERAL RECENT PSYCHIATRIC HOSPITALIZATIONS FOR ANXIETY AND SUICIDAL IDEATION, AND REQUIRED THE SUPPORT AND STRUCTURE OF DAY HOSPITAL PROGRAM TO PREVENT RELAPSE AND REHOSPITALIZATIO N.</content> </paragraph> </section>

Psychiatric symptoms

<section> <caption><caption_cd V="18661-9" S="2.16.840.1.113883.6.1"/> PSYCHIATRIC SYMPTOMS </caption> <paragraph> <content>PATIENT WAS AGITATED, ANXIOUS AND NEEDY, EXPRESSING FEARS OF ABANDONMENT AND PASSIVE SUICIDAL IDEATION. PATIENT REQUIRED FREQUENT REINFORCEMENT IN ORDER TO CONTINUE TO FUNCTION OUTSIDE OF AN INPATIENT PSYCHIATRIC WARD.</content> </paragraph> </section> </body> </levelone>

Figure 2 shows a portion of the computer-decision variant as rendered by a popular browser. It includes the medications rendered as a table.


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Figure 2. Rendered Portion of Compuer-Decision Variant.



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5 Response Code Sets

This section describes response codes that may be used in the computer-decision variant when the value table indicates a coded with exception (CE) data type or to represent units when the attachment component is of the numeric (NM) data type. The entry in the value table that refers to these code sets is used in the subsection titles.

The values for some code sets appear directly in this document. In other cases, the section cites another document as the source.

5.1 HL70136: HL7 Yes-No Indicator The OID for this table is 2.16.840.1.113883.12.136.

Table 5.1 HL7 Yes-No Indicator

Code HL7 Yes-No Indicator N No Y Yes

5.2 HL70162: HL7 Route of Medicine Administration

HL7 codes for route of medicine administration. The OID for this table is 2.16.840.1.113883.12.162.

Table 5.2 - Route of administration Value Description Value Description

AP Apply Externally MM Mucous Membrane B Buccal NS Nasal DT Dental NG Nasogastric EP Epidural NP Nasal Prongs* ET Endotracheal Tube* NT Nasotracheal Tube GTT Gastrostomy Tube OP Ophthalmic GU GU Irrigant OT Otic IMR Immerse (Soak) Body Part OTH Other/Miscellaneous IA Intra-arterial PF Perfusion IB Intrabursal PO Oral IC Intracardiac PR Rectal ICV Intracervical (uterus) RM Rebreather Mask* ID Intradermal SD Soaked Dressing IH Inhalation SC Subcutaneous IHA Intrahepatic Artery SL Sublingual IM Intramuscular TP Topical IN Intranasal TRA Tracheostomy* IO Intraocular TD Transdermal IP Intraperitoneal TL Translingual IS Intrasynovial UR Urethral IT Intrathecal VG Vaginal IU Intrauterine VM Ventimask IV Intravenous WND Wound MTH Mouth/Throat

*used primarily for respiratory therapy and anesthesia delivery


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5.3 HL79002: HL7 Rehabilitation Plan Status

The OID for this table is 2.16.840.1.113883.12.9002.

Table 5.3 HL7 Rehabilitation Plan Status

Code Rehabilitation Plan Status 700 Original 701 Update/Revision

5.4 HL79003: HL7 Rehabilitation Plan Continue/Discontinue Indicator


Table 5.4 HL7 Rehabilitation Plan Continue/Discontinue Indicator

Code Continue/Discontinue C Continue D Discontinue

5.5 HL79005: HL7 Rehabilitation Plan Prognosis The OID for this table is 2.16.840.1.113883.12.9005.

Table 5.5 HL7 Rehabilitation Plan Prognosis

Code Rehabilitation Prognosis 1 Poor 2 Guarded 3 Fair 4 Good 5 Excellent

5.6 HL79006: HL7 Rehabilitation Service Remission Status The OID for this table is 2.16.840.1.113883.12.9006.

Table 5.6 HL7 Rehabilitation Service Remission Status

Code Rehabilitation Services Remission Status 1 Early Full Remission 2 Early Partial Remission 3 Sustained Full Remission 4 Sustained Partial Remission



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5.7 HL79015: HL7 Frequency Base Period

This is a domain drawn from the HL7 iso+ system of units. It consists of codes to represent the denominator in an expression of frequency.


Table 5.7 HL7 Frequency Base Period

Code Frequency Base Period /sec per second /min per minute /hr per hour /d per day

/wk per week /mo per month /yr per year

5.8 I9C : ICD-9-CM International Classification of Diseases, Clinical Modification. The OID for this table is 2.16.840.1.113883.6.2

5.9 iso+: Extended ISO Units Codes ISO 2955-1983 and extensions as defined in HL7 Version 2.4 Figure 7-9. Due to its length the table is included in the HL7 Additional Information Specification Implementation Guide rather than in this Additional Information Specification.


5.10 NDC: National Drug Code The National Drug Code (NDC), administered by the FDA, provides a unique code for each distinct drug, dose form, manufacturer, and package. (Available from the National Drug Code Director, FDA, Rockville, MD, and other sources.)


5.11 NPI: National Provider Identifier On January 23, 2004, the Secretary of HHS published a final rule (Federal Register volume 69, page 3434) which establishes the standard for a unique health identifier for health care providers for use in the health care system, and announces the adoption of the National Provider Identifier (NPI) as that standard. It also establishes the implementation specifications for obtaining and using the standard unique health identifier for health care providers.

For more information contact the US Department of Health and Human Services, Centers for Medicare and Medicaid Services (CMS), 7500 Security Blvd., Baltimore, MD 21244

The DHHS Administrative Simplification web site is http://aspe.hhs.gov/admnsimp .

The OID for this table is 2.16.840.1.113883.4.6


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5.12 PTX: Health Care Provider Taxonomy

The National Uniform Claim Committee (NUCC) maintains the Health Care Provider Taxonomy. The code set is available through Washington Publishing. See: http://www.wpc-edi.com/codes/


--End of document--